Download CPAP AND THE BABY WITH DIFFICULT BREATHING

CPAP AND THE BABY WITH DIFFICULT
BREATHING
Medical Technology Transfer and Services
No 19 – Lane 399 – Au Co — Tay Ho – Hanoi — Vietnam
Tel: + 84 43 766 6521
Fax: + 84 43 766 3844
Email: [email protected]
www: mtts-asia.com
Breath of Life Program, East Meets West Foundation
ACKNOWLEDGEMENTS
This manual was written by Dr. Ingrid Bucens and designed by Mr. Andrew Mocny.
EMW is very grateful to the following people for the review and realization of this manual
during its development:
Dr. Priscilla Joe, Associate Director, Neonatal Intensive Care Unit and Director,
ECMO program at Oakland Children’s Hospital, California (USA)
Dr. Stephen Ringer, Chief, Division of Newborn medicine, Brigham and Women’s
Hospital, Boston (USA)
TABLE OF CONTENTS
List of Figures........................................................................................................................................... 8
List of Tables ............................................................................................................................................ 9
Abbreviations.......................................................................................................................................... 10
Part A
Babies with difficult breathing ................................................................................. 12
1
Apnoea ............................................................................................................................. 13
Associate Professor Trevor Duke, Paediatric Intensivist, Royal Children Hospital,
Melbourne (Australia)
1.1
What is apnoea? ............................................................................................. 13
1.2
What causes apnoea? ................................................................................... 13
Apnoea of prematurity ............................................................................... 13
Apnoea due to underlying disease......................................................... 14
Apnoea due to airways obstruction ....................................................... 14
Assistant Professor Dr. Maneesh Batra, Neonatologist
Ms. Ester McCall, Neonatal Nurse
Mr. Bruce Morrison, Medical Equipment Specialist, National Hospital GVof Dili
(Timor Leste)
1.3
Why is apnoea a problem? .......................................................................... 14
1.4
Managmenet of apnoea................................................................................ 16
Immediate management............................................................................ 16
Determine the cause ................................................................................. 16
Ongoing management .............................................................................. 16
Dr. Gaston Arnolda, M&E International Director, Breath of Life Program, East Meets
West Foundation
1.5
Mr. Luciano Moccia, International Director, Breath of Life Program, East Meets West
Foundation
Medications ................................................................................................ 18
Starting medications ................................................................... 18
Care whilst on medication .........................................................20
Stopping medications .................................................................20
Respiratory support ...................................................................................20
Ms. Danica Kumara, Regional Director for SE Asia, Breath of Life Program, East
Meets West Foundation
Mr. Gregory Dajer, Director, Medical Technology and Transfer Services (MTTS),
Hanoi (Vietnam)
Specific management for apnoea ............................................................. 17
1.6
2
Apnoea algorithm ........................................................................................... 21
Respiratory distress ....................................................................................................22
2.1
What is respiratory distress? ......................................................................22
2.2
Recognising respiratory distress ..............................................................22
Severity........................................................................................................23
Aetiology of respiratory distress .............................................................23
2
CPAP and the Baby with Difficult Breathing
2.3
Evaluating the cause of respiratory distress.........................................25
2.4
Management of established respiratory distress ................................25
3
2.5
Emergency management ..........................................................................25
Ongoing management .............................................................................26
Specific therapies ......................................................................................28
6
How does CPAP work? ...............................................................................................50
Giving oxygen ..................................................................................................29
7
How is CPAP given? .................................................................................................... 51
When to give oxygen .................................................................................29
How to give oxygen ...................................................................................29
Photographs and illustrations of oxygen administration devices .....30
General principles for administering oxygen to neonates .................32
When commencing oxygen therapy ........................................32
Making changes to oxygen therapy .........................................33
When to reduce oxygen .............................................................33
When to stop oxygen ..................................................................33
2.6
5.3
8
7.1
Pressure driven CPAP ................................................................................... 51
7.2
Flow driven CPAP ........................................................................................... 51
How does the EMW CPAP machine work? ..........................................................52
8.1
Oximetry ............................................................................................................34
Brief summary of the commonest causes of neonatal respiratory
distress.............................................................................................................36
Hyaline membrane disease (HMD) ........................................................36
Meconium Aspiration Syndrome (MAS) ...............................................36
Transient Tachyphnoea of the Newborn (TTN) ...................................37
Pneumonia ...................................................................................................37
Part B
CPAP - Continuous Positive Airway Pressure.....................................................44
1
What is CPAP? ...............................................................................................................45
2
Why use CPAP? .............................................................................................................45
3
Characteristics of CPAP that make it suited for use in low resource
contexts ...........................................................................................................................45
4
When can CPAP be used? ......................................................................................... 47
5
4.1
CPAP for apnoea............................................................................................. 47
4.2
CPAP for respiratory distress ..................................................................... 47
4.3
Neonatal conditions which may respond to CPAP ..............................48
8.2
Contraindications ...........................................................................................49
5.2
Situations where CPAP is unlikely to work ............................................49
8.3
CPAP and the Baby with Difficult Breathing
Patient interfaces ...........................................................................................64
Cut ETT ........................................................................................................64
Nasal prong devices..................................................................................64
Fitted nasal face masks ............................................................................65
Endotracheal tube ......................................................................................65
9
How to use CPAP - medical and nursing protocols ..........................................67
9.1
When to start CPAP .......................................................................................67
Additional points.........................................................................................67
Preterm babies .............................................................................67
Bigger babies ...............................................................................68
Ventilation ......................................................................................68
CXR .................................................................................................68
9.2
4
Oxygen supply .................................................................................................62
Oxygen from a cylinder .............................................................................62
Oxygen from a wall outlet .........................................................................62
Oxygen concentrators...............................................................................63
When should CPAP not be used? ...........................................................................49
5.1
Parts of the CPAP machine .........................................................................52
Air compressor ...........................................................................................53
Blender and gas flows ..............................................................................53
Inspiratory/heating bottle .........................................................................55
Patient circuit .............................................................................................. 57
Expiratory/pressure bottle........................................................................58
Control box ..................................................................................................59
Front panel ....................................................................................59
Controls..........................................................................................60
LED displays .................................................................................60
Alarms.............................................................................................60
Back panel.....................................................................................60
General instructions for using an oximeter ...........................................34
2.7
CPAP for older babies ...................................................................................49
How to start CPAP..........................................................................................69
5
9.3
How to care for babies being treated with CPAP ................................70
9.8
Immediate response ..................................................................................70
The baby who is not responding ............................................................70
After making alterations to the settings.................................................70
9.4
Regular patient monitoring.......................................................................... 71
When to wean CPAP ................................................................................90
When to stop the CPAP ...........................................................................90
Protocol: Stopping CPAP ........................................................................90
10
The baby - what to monitor ...................................................................... 71
CPAP - What to monitor ...........................................................................72
Trouble-shooting the machine .................................................................73
Monitoring frequency ................................................................................73
9.5
6
10.2
11
Using and caring for the EMW CPAP unit .............................................................96
11.1
Checking the machine before use............................................................96
11.2
Turning on and adjusting the controls for operation ..........................97
11.3
Care in use ........................................................................................................98
11.4
Alarms ................................................................................................................98
11.5
Turning off the machine ...............................................................................99
11.6
Care of the CPAP unit between uses.......................................................99
Cleaning the CPAP unit............................................................................99
Assembling / reassembling the CPAP unit ........................................102
What if the baby is deteriorating? .............................................................83
CPAP and the Baby with Difficult Breathing
Job aides - bedside protocols ....................................................................95
The machine ................................................................................................95
The patient ...................................................................................................95
Medical protocol ........................................................................................95
Counseling for parents .............................................................................95
Regular patient care ......................................................................................76
Clinical signs ...............................................................................................83
Possible reasons for deterioration..........................................................83
Increasing CPAP settings when the baby deteriorates .....................84
Maximum settings ........................................................................84
Protocol: What to do when a baby is deteriorating............................84
Acute complications of CPAP which may cause deterioration........85
Tube obstruction ..........................................................................85
Pneumothorax...............................................................................86
Gastric distension ........................................................................86
Overdistension of the lungs ......................................................87
Sepsis .............................................................................................87
Minimal equipment list for CPAP ...............................................................93
Basic resuscitation supplies for neonates............................................93
Oxygen supplies .........................................................................................93
CPAP ............................................................................................................93
Support equipment ....................................................................................94
When to call the doctor.................................................................................75
Oxygen Saturations (Sp02) .....................................................................76
Medications .................................................................................................77
Feeding / fluids ...........................................................................................77
Patient comfort ...........................................................................................78
Fever ...............................................................................................78
Hunger............................................................................................78
Hypoxia / worse RDS .................................................................78
Pain .................................................................................................78
Care of the nose.........................................................................................79
Suctioning....................................................................................................79
Thermoregulation .......................................................................................80
Infection prevention ...................................................................................80
Positioning ................................................................................................... 81
The correct technique for suction .......................................................... 81
9.7
How to make CPAP work well in your hospital ...................................................92
10.1
Baby problem ..............................................................................................75
Machine problem .......................................................................................75
9.6
Weaning and Stopping CPAP .....................................................................90
12
Nursing protocols .......................................................................................................103
12.1
Starting the baby on CPAP ........................................................................103
12.2
Care of the baby on CPAP .........................................................................104
12.3
Stopping CPAP ............................................................................................. 108
12.4
The patient interface — preparation, insertion, and fixation of a cut
ETT ....................................................................................................................109
Preparing the tube for insertion ............................................................109
Inserting the tube ..................................................................................... 110
7
Securing the tube .................................................................................... 110
Figure 5
Baby receiving oxygen through a headbox ..................................................... 31
12.5
Diagrams of 2 methods of taping tube insert ..................................... 110
Figure 6
Poor trace, pulse does not match patient (9) ................................................35
12.6
The patient interface - example fixation of nasal prongs ............... 112
Figure 7
Good trace, pulse matches patient (9) ...........................................................35
12.7
Counseling sheet for parents of babies on CPAP ............................. 113
Figure 8
Back of the blender .................................................................................. 55
Figure 9
Back panel of the CPAP ..................................................................................... 61
12.8
Pneumothorax protocol.............................................................................. 114
Figure 10
CPAP circuit .......................................................................................................... 61
Figure 11
A typical oxygen concentrator ...........................................................................63
Figure 12
Nasal erosions caused by CPAP patient interfaces ....................................79
Figure 13
Prone nursing on CPAP...................................................................................... 81
Figure 14
Secretions around the end of a cut ETT - it is easy to see how they may
cause complete obstruction ..............................................................................86
Figure 15
CXR showing large right sided pneumonthorax in an intubated baby ... 115
Figure 16
Draining pneumonthorax with a butterfly needle......................................... 117
Figure 17
Heimlich valve ..................................................................................................... 119
Figure 18
Correct placement and taping of an intercostal catheter ......................... 119
Signs that suggest a possible pneumothorax ................................... 114
Management of pneumothorax ............................................................. 114
Definitive management............................................................................ 115
Draining a pneumothorax with butterfly needle ................................. 115
Equipment .................................................................................... 116
Preparation .................................................................................. 116
Procedure .................................................................................... 116
Inserting an intercostal catheter (ICC) ............................................... 117
Equipment .................................................................................... 117
Preparation .................................................................................. 118
Post procedure .......................................................................... 119
12.9
Bedside monitoring chart for babies on CPAP ...................................120
13
Pretest/post-test........................................................................................................121
14
Case scenarios for CPAP training.........................................................................123
15
Sample timetable for a 1 day CPAP training.....................................................125
16
Tables
Table 1
Relationship between gestational age and incidence of recurrent apnoea
.................................................................................................................................. 13
Table 2
Causes of neonatal apnoea ............................................................................... 15
Supervision sheet......................................................................................................126
Table 3
Dosing regimens for Aminophylline (6) and Caffeine (7) ............................ 19
17
References....................................................................................................................129
Table 4
Causes of respiratory distress in neonates .................................................... 24
18
Annex 1: Oxygen concentration rates..................................................................132
Table 5
Different oxygen concentrations that are delivered at the specified flow
rates to a 5kg baby .............................................................................................. 31
19
Annex 2: Pretest/post-test (with answers)........................................................138
Table 6
Sources of oxygen ...............................................................................................32
20
Annex 3: Case scenarios for CPAP training (with answers) ........................ 141
Table 7
Different methods of administering oxygen to neonates (9) ......................39
Table 8
DDx of select common causes of neonatal respiratory distress ...............42
Table 9
Important differences between IPPV and CPAP ..........................................46
Figures
8
Figure 1
Sub-sternal recessions .......................................................................................22
Table 10
Patient interfaces .................................................................................................66
Figure 2
Nasal flaring (source: Managing newborn problems WHO 2003) ..........23
Table 11
Suggested start settings for CPAP for various conditions .........................69
Figure 3
Baby receiving oxygen through nasal prongs ................................................30
Table 12
Baby is deteriorating............................................................................................88
Figure 4
Placement of a single nasal catheter to give oxygen ...................................30
CPAP and the Baby with Difficult Breathing
9
ABBREVIATIONS
INTRODUCTION
ABG
Arterial blood gas
ICC
Intercostal catheter
AXR
Abdominal Xray
IPPV
Intermittent positive
pressure ventilation
Bid/bd
Twice daily
IVH
Intraventricular haemorrhage
BME
Biomedical engineering
KMC
Kangaroo Mother Care
BOL
Breath of Life
LED
Light emitting diode
BP
Blood pressure
MAS
Meconium aspiration
syndrome
BPD
Bronchopulmonary dysplasia
MTTS
Medical Technology Transfer
Services
BSL
Blood sugar level
Ng
Nasogastric (tube)
CO2
Carbon dioxide
Og/OGT
Orogastric (tube)
CPAP
Continuous Positive Airways
Pressure
O2
Oxygen
CXR
Chest Xray
PDA
Patent ductus arteriosus
This manual, CPAP and the Baby with Difficult Breathing, has been written with the
intention of assisting doctors and nurses to understand and to use the Breath of Life
(BOL) CPAP machine. The manual is in 2 parts. The first part, The Baby with Difficult
Breathing, gives an overview of the two clinical indications for CPAP in neonates; apnoea
and respiratory distress. The second part, CPAP, focuses on the machine itself and the
treatment of neonates with CPAP. A detailed index is on the following page.
SPECIFIC CHAPTER LEARNING OBJECTIVES
To understand how to recognise babies with apnoea and babies with
respiratory distress.
To know how to correctly manage babies with apnoea and babies with
respiratory distress.
To understand what CPAP is.
EBM
Expressed breast milk
PEEP
Positive end expiratory
pressure
ETT
Endotracheal tube
Qid
Four times daily
EMW
East Meets West
RD
Respiratory distress
To understand when to use CPAP.
FBC
Full blood count
RDS
Respiratory distress
syndrome
To be able to safely and correctly use CPAP.
FiO2
Inspired oxygen concentration
ROP
Retinopathy of prematurity
FRC
Functional residual capacity
RR
Respiratory rate
GI
Gastrointestinal
SpO2
Oxygen saturation
HB
Haemoglobin
Tid
Three times daily
Hct
Haematocrit
TTN
Transient tachypnoea of the
newborn
HMD
Hyaline Membrane Disease
USS
Ultrasound
HR
Heart rate
10
CPAP and the Baby with Difficult Breathing
To know how the CPAP machine works.
To be able to safely and correctly care for the baby being treated with
CPAP.
The material in this manual can be used in various different ways, either for individual or
group learning, with or without a facilitator. Material is presented in text form as protocols
and bedside Job aides. There are also practical exercises and supervision tools. Sufficient
materials are provided for a complete training and follow-up exercise.
11
PART A
BABIES WITH DIFFICULT BREATHING
Sick neonates often have difficulty breathing. It may signal primary lung problems or may
be a sign of other diseases or conditions. It is important that clinical staff working with
neonates are competent in recognising and correctly managing babies with these problems,
within the limits of available resources. In this manual both apnoea (inadequate breathing)
and respiratory distress are considered. General aspects of each including definitions,
classification, causes and management strategies are addressed. The manual is specifically
written to accompany the acquisition of the EMW CPAP machine. It is not meant to be a
comprehensive textbook on neonatal respiratory problems and their management; the reader
is referred to standard textbooks of neonatology for further details.
1.
APNOEA
1.1
What is apnoea?
Apnoea is an abnormally long pause, or complete cessation, of breathing. The precise
technical definition of apnoea is
A pause in breathing of greater than 20 seconds or a pause in breathing
of less than 20 seconds that is associated with bradycardia (< 100
beats/min) and / or cyanosis (1).
It is necessary to define an ‘abnormally long pause’ (20 seconds) because it is normal for
some babies, especially preterms, to have intermittent pauses in their breathing. This is
called periodic breathing. In periodic breathing, pauses last only 5-10 seconds and are not
associated with either bradycardia or cyanosis. Periodic breathing is not pathological and
does not require treatment. Babies who have periodic breathing ‘grow out of it’ with time.
1.2
What causes apnoea?
There are 3 main causes of apnoea:
– Apnoea due to prematurity
– Apnoea due to underlying disease
– Apnoea due to airways obstruction
Apnoea of prematurity
Apnoea is common in preterm babies. The more preterm a baby, the more likely it is to
have apnoea of prematurity (table 1). Most babies < 30 weeks gestation have apnoea of
prematurity.
Table 1. Relationship between gestational age and incidence of recurrent apnoea
Gestational age
Incidence of recurrent apnoea1
< 30 weeks
80%
30 - 31 weeks
50%
32 - 33 weeks
14%
34 - 35 weeks
7%
Apnoea of prematurity is due to immaturity of the central nervous system. The part of the
brain that controls the ‘drive to breathe’ is not fully developed. Apnoea of prematurity can
therefore be considered to be ‘physiological’ or part of a normal developmental process.
However apnoea of prematurity can cause hypoxia so it must be treated. Apnoea of
prematurity usually starts on day 1 or day 2 of life. Apnoea that begins within hours of birth,
12
CPAP and the Baby with Difficult Breathing
13
or more than 1 week after birth, is unlikely to be apnoea of prematurity. Babies ‘grow out of’
apnoea of prematurity as they mature. Most cases have resolved by 34-36 weeks. It is rare
for apnoea to continue at term however babies with chronic lung disease1 may take longer to
outgrow their apnoea.
Apnoea due to underlying disease
Apnoea is a common symptom of many different diseases that occur in the neonatal period
(table 2). Any of these conditions may cause apnoea in both term and preterm babies. In
preterm babies, any one of these conditions may worsen underlying apnoea of prematurity.
Apnoea due to airways obstruction
This is the least common cause of apnoea. Babies who have abnormal airways anywhere
from the mouth (e.g. Pierre Robin syndrome) down to the lower airways (eg tracheobronchomalacia) are prone to apnoea due to narrowing and or collapse of airway passages,
particularly during sleep.
1.3
Why is apnoea a problem?
Table 2. List of underlying diseases which may cause apnoea
UNDERLYING DISEASE
Systemic condition
Hypoxia
Hypothermia
Sepsis
Shock
Severe anaemia
Polycythaemia
Cardiac
Cardiac failure
Patent ductus arteriosus
Metabolic problem
Hypoglycaemia
Electrolyte disturbance (Na +, Ca ++ etc)
Rare congenital diseases
Brain disease
Asphyxia
Meningitis
Haemorrhage
Seizures
Congenital malformation
Drugs causing CNS depression (diazepam, morphine)
Lung disease
Any cause of respiratory distress resulting in FATIGUE (eg
pneumonia, HMD).
Bronchiolitis (RSV infection)
Pertussis infection
Gastro-intestinal
Severe gastro-oesophageal reflux
Aspiration
Necrotising enterocolitis
Airways obstruction
Choanal atresia
Micrognathia
Macroglossia
Tracheomalacia
If apnoea is prolonged and not treated it will cause hypoxia and bradycardia.
If unrelieved, apnoea can be fatal.
Apnoea in premature babies must never be assumed to be due to
prematurity. Other ‘pathologic’ causes must be excluded before attributing
apnoea to prematurity. Babies who are stable on treatment for apnoea of
prematurity may deteriorate if they develop an intercurrent condition that can
cause apnoea in its own right.
1
Babies who still require oxygen to maintain saturations in normal range at 36 weeks corrected
gestation.
14
CPAP and the Baby with Difficult Breathing
15
1.4
Management of apnoea
iii. Give glucose if hypoglycaemic (BSL < 2.5mmol) or if unable to exclude
hypoglycaemia (unable to quickly check blood glucose)
iv. Give antibiotics (ampicillin / penicillin and gentamicin or, in severe cases,
cefotaxime / ceftriaxone) unless sepsis can be excluded
v. Start CPAP if no response to medication (apnoea continues)
vi. Intubate / ventilate (if this is an option) if spontaneous respiratory drive
doesn’t return, if apnoea is prolonged or severe or if CPAP fails.
b. Supportive care
i. Monitor for further apnoea, desaturation and bradycardia with electronic
monitoring (SpO2 monitor) if available. If this is not an option, close nursing
observation is essential.
ii. Teach parents to observe for apnoea, how to give tactile stimulation and to
call for help if their baby has apnoea.
iii. Avoid vigorous suction which may exacerbate apnoea
iv. Give oxygen if needed to keep SpO2 in safe range (p. 76).
v. Maintain temperature in normal range
vi. Avoid hypoglycaemia
– Intermittent blood glucose checks if possible
– Ensure appropriate glucose intake with IV fluids or feeds 3
vii. Feed when it is safe to do so. Feeds should be witheld if apnoea is frequent
or severe and the baby will need IV fluid until he is stable. It is safer to feed
using og/ng tube if apnoea is ongoing, the baby is unstable or the baby is on
CPAP.
viii. Nurse in prone position or Kangaroo Care unless contraindicated as this will
help reduce apnoea of prematurity (3)
ix. Consider blood transfusion if Hct < 30 and recurrent apnoea
THERE ARE 3 COMPONENTS TO THE MANAGEMENT OF APNOEA
Immediate emergency management
Determining the cause
Ongoing treatment (medication +/- respiratory support)
Immediate management
Immediate management of apnoea focuses on reversing and preventing hypoxia. The
steps are as follows:
a. tactile stimulation (10 seconds only)
b. clear (suction) and position the airway
c. if no immediate response, ventilate with bag / mask; use oxygen if SpO2 < 90% and
call for help
d. if spontaneous breathing does not recommence after ~ 15 minutes of bag / mask
ventilation, consider intubation / ventilation2
Determine the cause
As soon as the baby is stable, review the history for risk factors for causes of apnoea,
examine the baby for signs of any of the causes of apnoea and perform basic investigations
if possible.
a. History: Consider risk factors (gestation, sepsis risk, birth asphyxia, drugs, other)
b. Examine: For signs of disease (temperature, anaemia, signs of sepsis, signs
of neurological disease such as bulging fontanelle and seizures, congenital
abnormalities, cardiac problem, respiratory distress etc.)
c. Investigations: Check blood glucose, FBC, Hct, electrolytes and blood cultures if
possible. Consider urinalysis, CXR, AXR, USS head, ABG if these are available and
if indicated from history and examination.
1.5
Aside from specific treatments for any underlying conditions, there are two treatments for
apnoea:
1. medications
2. respiratory support
Medication is the first line treatment for apnoea of prematurity unless the
baby has apnoea that is very severe or prolonged. For apnoea of other
causes CPAP or ventilation is the treatment of first choice.
Ongoing management
Ongoing management involves general supportive care as well as care specific to apnoea
and its cause.
a. Specific
i. If apnoea of prematurity, start stimulant medication (below)
ii. Provide any treatment specific to the cause
2
CPAP is unlikely to be effective if there is no spontaneous breathing after a prolonged apnoea.
Intubation / ventilation may be considered earlier depending upon the skills of available personnel, availability of
equipment and the safety of ongoing ventilation.
16
CPAP and the Baby with Difficult Breathing
Specific management for apnoea
3
For details refer to Managing Newborn Problems (WHO 2003) or other relevant text.
17
18
CPAP and the Baby with Difficult Breathing
IV: dilute 50mg/5mL
ampoule with
20ml water for
injection. Solution =
50mg/25mL (2mg/
mL).
ORAL: give with feeds
Not necessary
If HR > 180 per minute at
rest consider witholding the
dose.
infuse over
30mins
Oral:10mg/ml
IV: 50mg/5ml
ampoule
no need to
dilute
20mg/kg iv/o
250mg/10ml
ampoule
Caffeine citrate
(2mg caffeine
citrate = 1 mg
caffeine base)
24 hr later
5mg/kg od oral or iv
over 30mins
40-80 mmol/L
If available
IV: 0.4ml of
250mg/10ml solution
added to 4.6ml normal
saline gives 2mg/ml.
10mg/kg iv
over 60mins
diluted in
normal saline
Aminophylline
How
For maximum effectiveness, both aminophylline and caffeine require a loading dose (table
3). Regular dosing is then continued twice daily (bd) for aminophylline or, if using caffeine,
only once a day.
Regular dose
Medications are not used prophylactically. However, in developed country settings, all
preterm babies (< 34 weeks) are continuously monitored with electronic devices and
apnoea is quickly detected and treated. In resource limited settings electronic monitoring
equipment is rarely available. Human resources are also limited so patient observation is
infrequent. Prophylactic and safe monitoring is not the reality. Babies develop apnoea
unseen, sometimes with severe consequences. For this reason, in resource limited
contexts it is reasonable to begin stimulant medication in all preterm babies (eg < 32
weeks or < 1.5kg) to try and prevent apnoea and its consequences. The risk of starting
the medication (side effects, medication errors) is balanced by the risk of unwitnessed
apnoea and its consequences.
Loading
dose
Medications are also used prior to extubating preterm babies.
Drug and
preparations
1. a baby < 30 weeks gestation has any apnoea
2. a baby > 30 weeks has 2 or more apnoea requiring stimulation
Table 3. Dosing regimens for Aminophylline and Caffeine
When
In wealthy countries stimulant medications are started when babies are recognised to have
apnoea
of prematurity. Commonly medication is started when:
To make for
administration
levels
Starting medications
12 hr later
1st wk: 2.5mg/kg/
dose bd
2nd wk: 4mg/kg/dose
bd
> 2nd wk: 5mg/kg/
dose bd
slow bolus / 10mins
Can use iv solution
orally once on full
feeds
Aminophylline and caffeine are equally effective however caffeine is preferred as it is safer
and simpler to use. Compared with aminophylline, caffeine causes fewer side effects, only
needs to be administered once a day and it does not require blood monitoring of drug levels
(4). Caffeine also reduces overall neonatal mortality, long-term disability and chronic lung
disease in preterm babies who were ventilated (5). Unfortunately caffeine is not routinely
available in low-resource countries.
Observe for tachycardia
prior to administration.
Side effect monitoring
Two medications, aminophylline and caffeine, are used in the management of apnoea. They
work by stimulating breathing and diaphragmatic contraction. Both medications are effective
and safe in the management of apnoea of prematurity (2). They also reduce apnoea after
extubation in babies who have been ventilated. Apnoea of other causes and apnoea in term
babies is unlikely to respond to these medications.
sample taken mid dose or
pre-dose
Medications
19
Care whilst on medication
1.6
Apnoea Algorithm
Babies being treated with aminophylline should have serum levels monitored in order
to titrate the dose and avoid side effects. Side effects include tachycardia, jitteriness,
irritability, feed intolerance, vomiting and hyperglycaemia. If given too quickly serious cardiac
arrhythmias may occur. Unfortunately serum aminophylline levels are rarely available in low
resource contexts. Instead clinicians must observe closely for the presence of side effects
(especially tachycardia) which would suggest possible toxicity and may warrant a reduction
in dose.
In order to avoid medication errors and to reduce the risk of infection associated with IV
medication administration, stimulant medications should be given orally as soon as it is safe
to do so. This usually means when the baby is stable on full oral feeds.
Stopping medications
Medications for apnoea, either aminophylline or caffeine, can be stopped when the baby
has reached a gestational age of 34 weeks and when the baby has had no apnoea for at
least one week. Ideally babies should continue to be monitored with electronic monitoring
for one week after stopping medication. As this is not a reality in low resource contexts,
parents should be taught the signs of apnoea or cyanosis and should know how to stimulate
the baby and to call for help. Babies should never be discharged from hospital on stimulant
medications. They must have been well and free of apnoea for at least one week before
discharge.
Respiratory support
Both CPAP and intubation / ventilation, where available, have a place in
the management of apnoea. The role of CPAP for treating apnoea and how
to use CPAP for apnoea is discussed in detail in the second part of this
chapter.
20
CPAP and the Baby with Difficult Breathing
21
2.
RESPIRATORY DISTRESS
2.1
What is respiratory distress?
Respiratory distress is the term used to describe a combination of clinical signs that
commonly occur when a baby has difficulty breathing.
– tachypnoea
– grunting
– recessions (intercostal, subcostal, suprasternal, sternal)
– nasal flaring
– cyanosis
2.2
Reproduced from the CD of the Pocket Book of Hospital Care for Children, WHO 2005
Head Nodding: up/down movement of the head in time with respiration; caused by
accessory use of the suprasternal muscles.
Nasal flaring: Nasal flaring refers to movement of the external nares with each
breath.
Recognising respiratory distress
Most readers of this manual will be familiar with recognising the signs of respiratory distress.
Explanations are included here for completeness:
Tachypnoea: Tachypnoea is abnormally fast breathing. In a neonate this is defined
as a respiratory rate of > 60 breaths / minute. When counting respiratory rates it is
important to count for a full minute when the baby is settled. Counting for shorter
times can over or underestimate the real rate.
Figure 2. Nasal flaring (source: Managing Newborn Problems WHO 2003)
Cyanosis: Cyanosis is a blue discolouration of the central mucous membranes (lips,
gums) and indicates hypoxia. However cyanosis is generally only detectable when
oxygen saturations are below 90%. Therefore it is a late sign of hypoxia. Lesser
degrees of hypoxia may not be detected unless SpO2 monitoring is available 5 .
Recessions: Recessions are indrawings of soft tissues on or around the chest
during inspiration. They occur because disease makes the lungs ‘stiff’ (less
compliant) and the baby has to use the extra muscles and tissues to help inflate the
lungs to breathe.
Grunting: Grunting is an expiratory noise which occurs when a baby’s lungs are
stiff. It is caused because the baby is forcing air through partly closed vocal chords
in an attempt to make its own CPAP to try and keep the lungs open during expiration.
Severity
When respiratory distress becomes severe, babies become tired and their respiratory
muscles FATIGUE. The baby’s respiratory drive may be affected. Babies may begin to have
periods of hypoventilation (respiratory rate < 30 / minute), ‘gasping’ (slow, deep, abnormal
breaths) or apnoea. Apnoea associated with severe respiratory distress occurs in both
term and preterm babies.
Aetiology of respiratory distress
Respiratory distress may be caused by a wide variety of conditions. Most commonly it
is caused by lung conditions however it may also be present in various extra-pulmonary
conditions, see table.
Figure 1. Sub-sternal recessions
22
CPAP and the Baby with Difficult Breathing
23
Table 4. Causes of respiratory distress in neonates
Respiratory system
Lung disease
Hyaline Membrane disease (HMD)1
Pneumonia
Meconium Aspiration syndrome
Other aspiration
Transient tachypnoea of the newborn (TTN) also called ‘wet lung’
Pulmonary haemorrhage
Congenital malformations eg cystic abnormalities
Pulmonary hypoplasia
Pleural space
Pneumothorax
Pleural effusion
Airways
Airways obstruction
2.3
Clinical assessment (history and examination) together with a limited set of investigations,
when available, help determine the likely cause of respiratory distress. Knowing the probable
cause influences management to some degree and enables the clinician to predict the likely
course of illness. Important features of history and examination which help to differentiate
between common lung problems are shown in table 4 (p. 24).
Wherever possible, babies with RDS should have a chest Xray (CXR) and a sepsis screen
(FBC including haematocrit, blood cultures). A CXR is the most helpful investigation. It is
diagnostic of some conditions and is useful in confirming the severity of some conditions. It
is the only reliable means of diagnosing a pneumothorax.
CXR may not be readily available in some resource poor countries, portable CXR even less
so. Portable CXR is the safest X-ray to do if a baby is very sick because very sick babies
often deteriorate with the handling involved in transport.
If portable CXR is not available and a baby is very sick then it is often safer
to begin treatment and to delay the CXR until the baby is more stable.
Extrapulmonary
Cardiac disease
Cardiac failure with pulmonary oedema
Persistent pulmonary hypertension (PPHN)
Gastrointestinal
Congenital diaphragmatic hernia (CDH)
Tracheo-oesophageal fistula
Systemic process
Sepsis
Shock
Hypoglycaemia
Hypothermia
Muscle disease (myopathy)
The purpose of including this table is to remind the clinician that fast or difficult breathing is
not always due to primary lung disease. The commonest of these conditions are discussed
in more detail on the following page.
24
Evaluating the cause of respiratory distress
CPAP and the Baby with Difficult Breathing
2.4
Management of established respiratory distress
The management of respiratory distress includes the following steps:
1. Emergency management.
2. Ongoing management
a. supportive care
b. specific therapies
Emergency management
1. Correcting hypoxia:
a. If a saturation monitor is available, all babies with respiratory distress should have
their oxygen saturation (SpO2) checked and oxygen should be given to try and
return SpO2 to normal.
i. Very preterm babies (< 32 weeks or < 1.5kg) are at risk of eye damage from
oxygen treatment. This is further explained on p. 29. In these babies give
oxygen if SpO2 is < 85% and keep SpO2 85-93% (8).
ii. In term babies who have suspected asphyxia, sepsis, meconium aspiration
or pulmonary hypertension, give oxygen if SpO2 < 95% and keep SpO2 >
95% (9, 10).
iii. In all other babies give oxygen if SpO2 is < 90% and keep SpO2 90-95%.
b. If SpO2 monitoring is not available and the baby has central cyanosis or severe
respiratory distress (RR>70, severe retractions, head nodding, inability to feed) or
depressed conscious state, oxygen should be given.
c. How to give oxygen is further explained below. See ‘GIVING OXYGEN’.
25
2. Correcting hypoventilation, gasping or apnoea: A baby with respiratroy distress
may develop hypoventilation (respirations < 30 per minute), gasping or apnoea due to
fatigue. If apnoea is present this must be immediately managed as above. If a baby has
hypoventilation, observe very closely for apnoea. If respiratory rate drops below 20 /
minute, if the hypoventilation is associated with hypoxia or if there are gasping breaths
then support with bag and mask (and oxygen). It is very likely CPAP or ventilation (if
available) will be required.
Ongoing management
Supportive care: Elements of supportive care are very important in care of the baby with
respiratory distress. Paying careful attention to supportive care increases the effectivess of
CPAP and other specific therapies.
1. Oxygen: Giving oxygen directly increases blood oxygen levels. It further increases
blood oxygen because it increases blood flow to the lungs (by decreasing pulmonary
vascular resistance). Oxygen should be given and continued to keep SpO2 in the
desired range (above).
2. Antibiotics: Antibiotics should be given to cover possible infection. Begin with
Ampicillin / Benzyl Penicillin + Gentamicin. In very severe cases, or in babies who
may have staphylococcal disease,4 it is better to use Cloxacillin + Gentamicin or
Ceftriaxone/Cefotaxime. Antibiotics should be continued until infection can be excluded
on clinical grounds (there is another clear explanation for the respiratory distress) or
after investigations exclude infection (normal wbc, negative cultures).
Antibiotic
Dose (6)
Ampicillin
50mg/kg iv bd (1st wk) or qid (2nd-4th wks)
BenzylPenicillin
60mg/kg/dose bd (1st wk) or qid (2nd-4th wks)
Gentamicin
<30wk, 2.5mg/kg/dose od
30-35wk, 3.5mg/kg/dose od
term 1st wk, 5mg/kg/dose od
term 2nd-4th wks, 7.5mg/kg/dose od
Cloxacillin / flucloxacillin
25-50mg/kg/dose bd (1st wk) or tid (2nd-4th wks)
Ceftriaxone #
25-50mg/kg daily (1st wk), bd (2+wks)
Cefotaxime #
25-50mg/kg bd (preterm or 1st wk), tid/qid (2-4wks)
# Of these 2, cefotaxime is preferred in neonates as ceftriaxone may exacerbate jaundice
3. Abdominal decompression: An oro or nasogastric tube should be inserted and left
open on free drainage. This prevents gastric distension which will further compromise
respiration.
4
Suggestions of staphylococcal disease include associated pustular skin lesions, bullae or effusions
on CXR.
26
CPAP and the Baby with Difficult Breathing
4. Thermal control: Both hyperthermia and hypothermia can worsen a baby’s respiratory
status and may cause apnoea. Temperature monitoring and keeping the baby’s
temperature in the normal range reduces metabolic demands which in turn minimises
oxygen requirement and keeps the baby more stable. See the manual on the EMW
radiant warmer.
5. IV Fluids: Most babies with respiratory distress should receive IV fluids until their
respiratory status is stable, improving and they can be safely fed. It is normal to use IV
fluids and withold feeds in babies with respiratory rates > 70/minute and / or other signs
of significant respiratory distress. A guide to IV fluid volumes, which depend on weight
and age, can be found in Managing Newborn Problems, WHO 2003. In respiratory
distress high volumes of IV fluids should be avoided.
6. Feeding: It is important to feed babies as soon as it is safe to do so, preferably with
expressed breast milk. However, when a baby has respiratory distress it is safest to
withhold feeds because of the risk of aspiration. The mother should express and store,
or discard, her milk and the baby should be given IV fluids. When the baby is stable and
respiratory distress is not severe, small volume feeds can be started, usually by og or ng
tube. They are gradually increased as tolerated and according to the baby’s respiratory
status. Large volume feeds should be avoided until the baby’s respiratory status is
normal; it is safer to feed small amounts more frequently. For a guide to feeding see
Managing Newborn Problems, WHO 2003.
7. Suctioning: It is important to maintain a clear airway however suction must be done
cautiously and using correct technique. Suctioning too frequently or too vigorously can
cause apnoea and bradycardia. Suction only when secretions are present or if the baby
has deteriorated. Suction must be brief and catheters must not be inserted too deeply.
See p. 79 for suctioning protocol.
8. Vital signs monitoring: Ideally babies with respiratory distress requiring treatment
should have continuous electronic monitoring of vital signs and oximetry. This is
unrealistic in low resource settings and must be replaced with frequent nursing
observations in a frequency determined by the doctor. Very sick babies require hourly
observations.
9. Blood monitoring: Ideally babies on IV fluids should have daily monitoring of
electrolytes and haemoglobin should be checked twice weekly. Electrolyte abnormalities
must be corrected. If a baby requires oxygen, blood should be transfused to keep Hb
> 8g/dl (if respiratory distress is severe, keep Hb > 10g/dl). Blood glucose should
be checked twice a day until it is stable and the baby is on feeds; it may need to be
checked more often if there is any hypoglycaemia. IF blood gas monitoring (ABG) is
available and if there is facility to offer ventilation to babies with respiratory failure then
ABG should be checked daily and during periods of instability.
10. General nursing: Positioning the baby with the head raised by ~ 30o may improve
27
respiratory status. Use pillows under the mattress or raise the bed head if possible.
Using the prone position may also help respiration and may reduce apnoea; be careful
not to obstruct the baby’s face. Handle the baby for cares, procedures as little as
possible because activity will increase oxygen requirement.
Specific therapies
When babies have hypoxia that does not respond to oxygen and other supportive care, or
apnoea or increasingly severe respiratory distress, they need further support to breathing.
This can be temporarily provided with bag / mask ventilation but, if ongoing support
is needed, then the baby requires either CPAP or intubation and ventilation. CPAP is
increasingly used as first line respiratory support for babies with respiratory distress.
How and when to use CPAP is discussed in detail in the second part of this
manual.
2.5
Giving Oxygen
When to give oxygen
Oxygen should be given to all babies with hypoxia, as determined by SpO2 monitoring (box).
Where oximetry is not available, clinical signs must be used as a proxy for hypoxia. Babies
with cyanosis and / or moderate-severe respiratory distress (RR > 70, severe retractions,
head nodding, grunting, or inability to feed) as well as babies with depressed level of
consciousness should be given oxygen (9).
In very preterm babies (<32 weeks or <1.5kg) give oxygen if
SpO2<85%.
In term babies with specific conditions including sepsis, asphyxia,
meconium aspiration or pulmonary hypertension, oxygen should be given
when SpO2 < 95% (9, 10).
In all other babies Oxygen should be given when SpO2 < 90%.
How to give oxygen
Devices for administration 5
There are several ways that free flow oxygen can be administered:
– Nasal Prongs (also called nasal cannulae)
– Single nasal catheter
– Face mask
– Head box
– Incubator (free flow into incubator)
– Bag / mask ventilation
Babies who have inadequate breathing (hypoventilation, gasping or apnoea)
as well as hypoxia need to have bag / mask support to breathing with
oxygen. Other methods of oxygen administration are unsuitable.
Table 5 (p.31) lists the advantages and disadvantages of each of these modes of oxygen
delivery. The method selected for delivering oxygen to a particular baby needs to take these
issues into account and will depend upon the availability of delivery devices. In resource
limited settings oxygen supply is often limited. If oxygen supply is limited, prongs and
catheters should be used instead of masks, headboxes and incubator oxygen as these 3
methods all use high flows and waste oxygen unnecessarily. Prongs and catheters also have
5
Nasopharyngeal catheters have also been used to deliver oxygen to neonates however their use is not
included here due to the significant safety hazards associated with their use. These hazards make it difficult to
recommend their use in low resource contexts.
28
CPAP and the Baby with Difficult Breathing
29
the advantage of delivering some ‘PEEP’6 (like CPAP) as well as administering oxygen.
In low resource settings, considering patient safety and cost as priorities,
nasal prongs are the preferred method of administering oxygen in most
circumstances.
Photographs and illustrations of oxygen administration devices
Figure 5. Baby receiving oxygen through a headbox
Figure 3. Baby receiving oxygen through nasal prongs
The concentration of oxygen that can be supplied using different delivery devices differs.
Prongs, catheters and masks are not able to give 100% oxygen because, when the baby is
breathing, the oxygen supplied through the device is mixed with ambient room air which the
baby breathes in alongside the oxygen delivery device. The inspired oxygen concentration
also varies according to size, respiratory rate and effort, the seal of the device and the
oxygen flow rate. Table 5 below illustrates this. The figures in this table have been calculated
for a baby of ~ 5kg and using flow rates recommended for the individual devices. More
detailed tables showing percent of oxygen delivered at different flow rates and for babies of
different weights are included for completeness as an annex (p. 132).
Table 5. Different oxygen concentrations that are delivered at the specified flow
rates to a 5kg baby
Oxygen
Delivery system
Flow l/minute
% Oxygen that is delivered
Nasal Cannulae / prongs
1
45
Nasal catheter
1
50
Simple Mask
6-10
35-55
Head box
>10
21-100
Figure 4. Placement of a single nasal catheter to give oxygen (9).
6
PEEP = positive end expiratory pressure
30
CPAP and the Baby with Difficult Breathing
31
Table 6. Sources of oxygen
Therefore babies who are breastfeeding will need either prong / catheter oxygen. Most
babies on oxygen are fed by nasogastric tube.
Oxygen can be sourced from cylinders, concentrators or pipes / wall outlets.
Source
Special
considerations
Advantages
Disadvantages
Oxygen
cylinder
Backup cylinder must
always be available.
Does not need
electricity to run.
Transportable.
Limited source – supply
runs out.
Flow regulator needed.
Oxygen
concentrator
Backup cylinder
needed in case power
or machine fails.
Very cost-effective after
initial purchase.
Simple to operate.
Needs reliable electricity.
Needs regular maintenance
/ cleaning.
Constant source.
Doesn’t need electricity.
High cost at initial set-up.
Needs maintenance.
Need flow regulator at each
outlet.
Piped oxygen
Needs oxygen machine
at site.
General principles for administering oxygen to neonates
1. Only administer oxygen where there is a genuine indication (hypoxia, apnoea or severe
respiratory distress) and stop as soon as oxygen is no longer required.
2. Monitor the baby’s clinical condition and response to oxygen therapy, When the vital
signs are checked, also check:
– SpO2 (if possible) or presence of cyanosis
– Other signs of difficult breathing
3. Monitor the supply / delivery of oxygen
– Is the baby getting the amount of oxygen that is prescribed (flow / concentration)?
– Is the method of delivering the oxygen being applied / used appropriately? (are the
tapes loose, is the mask falling off, is the baby slipping out of the headbox, etc.)
– Is the delivery system patent?
– Is the cylinder near empty?
These things should be checked at the same time as the patient observations. The
frequency of monitoring will depend upon the severity of the baby’s condition and will be
ordered by the doctor.
4. Do not disconnect the oxygen for cares, procedures, transfers etc. If the baby requires
oxygen it must be administered continuously. If the baby must be moved (eg for X-ray)
arrange for a portable form of oxygen. Sudden interruption of oxygen supply could
cause serious deterioration in a baby’s condition.
5. Oxygen should not be disrupted for feeds. If anything, babies require more oxygen
during feeding because the “work of breathing” is increased by the effort of sucking.
32
CPAP and the Baby with Difficult Breathing
6. For babies on low-flow oxygen (nasal catheters or prongs) there should always be a
mask close by (eg. hung on oxygen cylinder) so, in case of sudden deterioration, a
higher concentration of oxygen can be administered quickly.
When commencing oxygen therapy
–
–
–
–
–
–
–
–
Ensure equipment set up is correct
Ensure the oxygen source is working (check it is flowing by feeling for flow out the end
of the tubing)
Ensure baby’s airway is patent (need to suction nose and mouth)
Insert or attach device
Start at the minimum of the recommended flow (table 5 p. 31).
Continue to increase ‘concentration’ (increase flow to maximum possible with the
particular device – table 5) until cyanosis is resolved (baby is pink) and / or the
saturations are in the target range.
IF unable to obtain normal saturations on maximum flow consider changing to a device
which can administer higher concentrations (see table 5) OR consider if CPAP is
indicated.
If saturations are normal however respiratory distress is severe consider CPAP.
Making changes to oxygen therapy
–
–
–
–
Only make SMALL changes to the flow at a time
– If high flow change by 1L / time
– If moderate to low flow change by 0.1-0.5L at a time7
Always wait to observe the effect of the change for 15 minutes after the change
If signs of breathing difficulty increase / return after the change (the saturations reduce,
cyanosis returns or other signs of breathing difficulty increase) return the oxygen
treatment to its earlier quantity
After stopping oxygen therapy babies should be observed closely still for at least 24
hours
When to reduce oxygen
–
–
saturations in target range
improvement in signs of difficulty breathing
When to stop oxygen
–
–
7
saturations normal
no signs of difficulty breathing
A ‘low flow’ flow meter (range of flow = 0-2L/minute) is needed to do this accurately.
33
Do not forget the importance of supportive care for babies receiving oxygen
(p. 26).
2.6
Oximetry
Oximetry is the only way to accurately detect hypoxia and the only way
to detect hyperoxia. Both hypoxia and hyperoxia are dangerous. For this
reason, all facilities offering oxygen therapy should have at least one working
oximeter in the neonatal care area.
–
Too low alarm sounds because the probe is not attached properly
– Poor trace / pulse does not match baby’s pulse
–
Figure 6. Poor trace, pulse does not match patient (9)
When oximetry is available it may be used for continuous or intermittent assessment of
oxygen saturation (SpO2). Continuous monitoring is preferable because it gives an instant
reading and it requires less handling of the baby. However this will depend on the number
of babies on oxygen treatment and the availability of oximeters. Priority should be given to
the sickest babies and the smallest babies because oxygen treatment may be toxic in small
babies.
General instructions for using an oximeter
1. Select correct sized probe (using probes which are too big on a neonate will make it
difficult to secure and to get a good trace).
2. Disinfect the probe before use.
3. Attach probe securely to foot / finger / ear.
– If too loose the monitor will not detect the pulse accurately.
– If too tight or left on for long periods the probe can cause skin breakdown. If using
continuous monitoring you need to change the probe site every few hours.
4. Read the oxygen saturation from the machine.
– First ensure the machine is detecting the saturation correctly.
– Is the signal good?
– Does the pulse reading on the oximeter match the baby’s pulse?
– If the answer to either of these is “no” then reattach the probe before reading.
– Chart the result.
– Adjust the oxygen if the result is “too low” or “too high”.
5. If using the oximeter for continuous monitoring, set alarm limits before use.
– Set the “too low” alarm at 83% in preterm babies and at 88% in term babies.
– Set the “too high” alarm at 95% in preterm babies and 98% in term babies.
6. If the alarm sounds respond immediately. Assess the baby to determine why the
alarm is sounding. Determine if
– The baby’s SpO2 is really too low
– The trace is good / the pulse matches / the baby may be cyanosed
– The baby’s SpO2 is too high
– The trace is good / the pulse matches / the baby is pink
34
CPAP and the Baby with Difficult Breathing
Figure 7. Good trace, pulse matches patient (9)
RISKS OF OXYGEN THERAPY
Oxygen therapy can be harmful if used incorrectly. Both too little and too
much oxygen can be harmful.
Too little oxygen can cause damage to vital organs, like the brain and the
heart, particularly if it is severe or prolonged. Eventually too low oxygen
will cause permanent damage to these organs and / or death.
Too much oxygen can cause permanent damage to the lungs and, in
preterm babies, to the eyes (p. 76).
This is a brief overview only. For a comprehensive review of oxygen therapy the reader is
referred to The Clinical Use of Oxygen in Hospitals with limited resources. Guidelines for
health workers, hospital engineers and program managers (WHO 2009) (9).
35
2.7
Brief summary of the commonest causes of neonatal respiratory
distress
Hyaline Membrane Disease (HMD) also called Respiratory Distress Syndrome (RDS)
HMD is, with rare exception, a condition of preterm babies < 34 weeks. It is the commonest
respiratory disease and the commonest cause of mortality in preterm babies. The more
preterm the baby is the more likely it is to have HMD; about 50% of babies born < 30 weeks
will have HMD.
‘Hyaline membranes’ are a histological change seen by microscope. They are fibrous
layers formed by sloughed cells and exudate which line the alveoli in HMD. HMD is caused
by a deficiency of surfactant, a natural substance which facilitates inflation of alveoli by
reducing the forces (‘surface tension’) which make alveoli prone to collapse. Surfactant
production is incomplete before 34 weeks gestation. Surfactant insufficiency means that
the terminal air spaces (alveoli) are prone to collapse. Collapse reduces the volume of lung
available for gas exchange (reduced functional residual capacity) and makes the lungs stiff.
HMD presents with increasing respiratory distress within hours of birth. It worsens as
collapse becomes more widespread. Typically the disease is at its worst at 24-48 hours.
If the baby survives then improvement and resolution occurs 72-96 hours after birth. A
spontaneous diuresis marks this change.
The management of established HMD aims to support the baby through this time and to
limit further lung injury. Big progress in management has occurred over recent decades with
resulting improved preterm survival. The 2 key postnatal interventions are the administration
of surfactant (p. 67) and improved ventilatory strategies including CPAP. Prenatal
administration of steroids to women in preterm labour has also significantly reduced the
incidence and severity of HMD 8 .
In low resource contexts prevention of disease is particularly important. Every attempt
should be made to provide steroids to a mother in preterm labor, even if she may receive
only one dose prior to delivery. Surfactant is expensive so hospitals must determine whether
or not it is an affordable option and must develop policies for judicious use. The use of
CPAP for HMD is discussed in the next part of this manual. Ventilation strategies are not
covered here.
Meconium Aspiration Syndrome (MAS)
Meconium is produced by the fetal bowel. It may be released into the amniotic fluid if the
fetus experiences intrauterine asphyxia. Meconium stained liquor is present in ~ 15% of all
deliveries however meconium aspiration syndrome occurs in only 5 to 10% of all babies
with meconium stained liquor. Aspiration of meconium may occur in utero (asphyxia may
cause the fetus to gasp) or during delivery.
Meconium is an irritant and toxic to the lungs, producing inflammation and affecting
surfactant production. It also causes obstruction of the small airways which results in distal
collapse and areas of hyperinflated lung.
Babies with MAS have respiratory distress; their chest may appear ‘barrel shaped’ due
to the hyperinflated lung. They may have severe hypoxia which may be worsened by
secondary pulmonary hypertension. They may also have central nervous system asphyxia,
mild to profound, depending upon the severity of asphyxia. Severe asphyxia may cause
hypoventilation, gasping or apneoa at birth and, later, seizures, hypotonia and / or
unresponsiveness. This may of course result in permanent neurological deficit.
Management of MAS remains a challenge even in countries with no resource limitations.
There is little that can be done for the central nervous system asphyxia and the management
of the respiratory distress is difficult because of the frequent occurrence of pulmonary
hypertension and air leak syndromes. Good obstetric care is critical to minimise asphyxia
and to reduce incidence and severity of asphyxia. Delivery room management includes
direct visualisation and suction through the cords (using endotracheal tube +/- meconium
aspirator or other suction device) in babies who have respiratory depression at birth 9 .
Subsequent management of MAS includes surfactant lavage, inhaled nitric oxide and a
variety of ventilatory strategies including high frequency oscillation. CPAP may be useful in
milder cases.
Transient Tachypnoea of the Newborn (TTN)
TTN is also a condition largely of term babies. It presents as respiratory distress in the first
few hours after birth. It is thought to be due to delayed removal of fetal lung fluid which
is usually largely removed during delivery. It occurs most often in caesarean deliveries
and precipitate or breech births. The lack of a normal labour process impedes the usual
clearance of fluid.
The respiratory distress of TTN is typically not severe; it is rare for oxygen requirements to
go beyond 40% free flow oxygen, so it is rare for babies with TTN to need treatment other
than free flow oxygen. A few will need CPAP or even ventilation.
Unlike HMD, meconium aspiration syndrome (MAS) is a disease of term or post-term babies.
It is rare before 36 weeks. As suggested by the name, MAS is a condition where meconium
is aspirated into the lungs.
Pneumonia
8
Aside from preventing HMD, antenatal steroids also reduce neonatal mortality, necrotizing
enterocolitis, and intraventricular hemorrhage.
9
A recent multicentre randomised controlled trial found there was no advantage in oral and pharyngeal
suction as the head delivers (11).
36
CPAP and the Baby with Difficult Breathing
Pneumonia is a common cause of neonatal respiratory distress, particularly in low resource
contexts where infections make up a large proportion of morbidity at all ages. Pneumonia
may occur together with sepsis and / or meningitis. The infection may begin in-utero due to
37
38
CPAP and the Baby with Difficult Breathing
catheters.
nasopharyngeal
Safer than
Nasal catheter
Use 8F NGT.
Insert tube the distance from
nostril to inner margin eyebrow.
It should NOT be visible at the
back of mouth below uvula.
Insert in same nostril as any
NG feeding tube or use an OG
tube so as not to obstruct both
nostrils.
Remove and clean at least 2x
daily
Use correct sized prongs (1mm
preterm, 2mm term).
Tape tubing securely to baby’s
face (image above).
Clean prongs at least 2 x daily.
Minimum
0.5L/min.
Maximum
2L / min.
Minimum
0.5L/min.
Maximum 2L/
min.
Flow rates
Delivers a constant FiO2 if
administered correctly
When stable can feed whilst
oxygen being administered.
Unlikely to be dislodged.
Humidification not required.
Produces some PEEP.
Delivers constant FiO2 if
secured correctly.
When stable can feed whilst
oxygen being administered.
Impossible to insert too far.
Humidifcation not required.
Advantages
For more comprehensive information, and for information about the other causes of
respiratory distress, refer to standard textbooks of neonatology.
Preferred method
in most settings
as achieve best
balance of safety,
efficacy and
efficiency.
Nasal prongs
To use
Maximum flow 2L / min.
Need LOW FLOW meter for giving
the oxygen.
Small risk of displacement into the
oesophagus and gastric distension.
See additional note below
Need correct size prongs – too big
/ small not effective.
Maximum flow 2L / min.
Need LOW FLOW meter for giving
the oxygen.
Difficult to use if baby has a lot of
nasal secretions.
Prongs are costly.
Disadvantages
Maternal infection, prolonged rupture of membranes, preterm birth, manipulation in labour
and maternal carriage of group B streptococcus all predispose to neonatal pneumonia.
There is a wide variety of possible causative organisms (including bacteria, viruses and
syphilis) and relative prevalence varies between countries.
The consequences of neonatal pneumonia may be devastating, in particular if associated
with sepsis, septic shock or meningitis. Treatment includes specific antibiotic therapy,
respiratory support (oxygen, CPAP or ventilation) and other supportive care.
Method
Table 7. Different methods of administering oxygen to neonates
transplacental infection. These babies, born with congenital pneumonia, may be very unwell
at birth, with respiratory distress and / or apnoea, especially if there is concomitant sepsis or
meningitis. Infection may alternatively be acquired during birth, especially if there is maternal
chorioamnionitis due to prolonged rupture of membranes, or at any time in the days or weeks
after birth.
39
40
CPAP and the Baby with Difficult Breathing
41
Incubator
+/- headbox
–
–
–
As per
headbox
Minimum
2–3 L/kg/min.
Maximum:
high flow.
Minimum
3-4L / min.
Maximum:
high flow
Warms the oxygen before
delivery.
No attachments to baby’s
face – comfort and baby
can still be fed as face not
obstructed if headbox not
used.
Humidification not required.
No risk of airway obstruction
or of gastric distension.
Can measure FiO2 if have
an oxygen analyser.
Warms the oxygen before
delivery.
Humidification not required.
Can give a high FiO2 if
needed by using high flows.
High flows are not
dangerous (just wasteful).
No risk of airway obstruction
or of gastric distension.
Can measure FiO2 if have
an oxygen analyser.
Convenient for short periods
of use, for transport and for
urgent oxygen administration
(can set up quickly).
No risk of airway
obstruction.
Humidification not required.
Need high flow to give high FiO2 –
wastes oxygen.
Hard to maintain FiO2 – oxygen
escapes through portholes / doors
etc.
Need high flow to give high FiO2 –
wastes oxygen.
CO2 toxicity may occur if
inadequate low flows of oxygen
used.
Wasteful of oxygen as relatively
high flows needed.
Oxygen can escape out the neck
hole and mixes with air; FiO2 is not
very reliable.
Big babies can wiggle out of the
headbox.
Cannot feed the baby except by
tube.
At the time of writing this manual ‘high flow oxygen through nasal prongs’ is beginning to be used in neonatal nurseries
in developed countries.
Nasal prong oxygen delivered at flows higher than 2l/minute has been found to provide effective CPAP. The CPAP
provided varies according to the size of the baby and the fit of the cannulae (how much leak).
The oxygen must be warmed and HUMIDIFIED when used in this way.
As this method is still relatively new and has not yet been adequately studied in low-resource contexts, it is not discussed
further here.
Insert oxygen tubing through
hole in incubator side +/- use
headbox.
- Most effective if use a headbox
Head box
–
Select appropriate sized
headbox – if hole too big baby
will wiggle out; if hole too small
may impede ventilation.
Face mask
Select appropriate type of mask
– IF available, non rebreather
masks can deliver 100% oxygen.
These masks have an oxygen
reservoir with a one-way valve
which prevents expired air mixing
with the stored oxygen.
Select appropriate sized mask.
CO2 toxicity may occur if
inadequate low flows of oxygen
used, if the mask is too small or the
oxygen supply inadvertently runs
out!
Wasteful of oxygen as relatively
high flows needed.
Cannot feed the baby at same time
except by tube.
Mask can fall off if baby is active or
tapes loose.
Blows cold air onto the baby’s face.
42
CPAP and the Baby with Difficult Breathing
43
CXR:- hyperlucent lung fields
CXR:- varies depending on
pathology
May have cardiomegaly and
increased vascular markings
May have pulmonary oedema
(diffuse fluffy infiltrates) +/effusions, fluid in fissures
May have hyperlucent black lungs
and normal sized heart
RD
RD
Barrel chest or
unilateral inflation
Reduced breath
sounds 1 side
‘Tension’
Cyanosis
RD
+/- poor perfusion
+/- cyanosis
+/-RD
+/- murmur
+/- absent femoral
pulses
+/- Cardiomegaly
Signs of reduced
cardiac output
(hepatomegaly, poor
urine output and
perfusion)
+/- associated
congenital
abnormalities
Term
Caesarean section,
breech, precipitate
birth
IPPV
May have
underlying lung
disease (MAS,
HMD)
Asphyxia
Diabetic mother
Cyanosed from
birth
May be detected
on antenatal US.
Aspiration of
meconium inutero or during
birth.
Asphyxia.
Delayed
resorption of
foetal lung fluid
Positive
pressure
ventilation
Pneumonia
MAS
TTN
Pneumothorax
Congenital
cardiac disease
Congenital
Congenital
Asphyxia
Transillumination
CXR:- Air in pleural space,
collapsed ipsilateral lung. Maybe
shift of heart and mediastinum.
May be associated air leaks
(mediastinum, pericardial)
RD
Barrel chest
CNS depression
including
hypoventilation,
gasping, apnoea
Yellow stained skin
Meconium stained
liquor, especially if
thick particulate.
Asphyxia
Common in post
term, LBW but rare
< 34wk
Congenital
or postnatal
infection
Primary
Persistent
pulmonary
hypertension
CXR:- Diffuse hazy streaky
markings bilaterally (prominent
vascular markings), central fluid in
fissures.
RD
+/- apnoea
+/- septic, shocked
or CNS depression
Offensive liquor.
CXR:- Irregular ‘fluffy’ infiltrates,
areas hyperexpansion and
collapse. Maybe associated air
leaks.
CXR:- diffuse alveolar infiltrates,
uni or bi-lateral. Maybe similar to
HMD. Maybe effusions or bullae
especially with staph.
WBC may be high or low. +/thrombocytopaenia.
+ve blood cultures.
+ve maternal HVS, blood cultures,
placental swabs
CXR:- Diffusely hazy lungs with air
bronchograms.
Risk factors for
sepsis
Preterm,
prolonged rupture
membranes, labour
manipulation
RD begins within
hours of birth
Preterm
Preterm birth
Early onset RD
Deficiency of
surfactant
Prematurity
Investigations
HMD
Examination
History
Cause
Table 8. DDx of select common causes of neonatal respiratory distress
Definitive test is
Echocardiogram
May be associated
with other lung
conditions or
cardiac disease
or may be isolated
condition.
In HMD often
occurs when
compliance
improving, CPAP
or IPPV not
weaned quickly
enough.
Mild, self limiting.
FiO2 < 0.4
Unlikely if severe
RD.
May have
associated
pulmonary
hypertension.
May have
associated sepsis
+/- shock and
meningitis.
Peaks 24-48h,
resolves 72-96h
with diuresis.
Other
1.
PART B
CPAP - CONTINUOUS POSITIVE AIRWAY PRESSURE
WHAT IS CPAP?
CPAP is a treatment for neonates with apnoea and with respiratory distress. “CPAP” stands
for Continuous Positive Airways Pressure – it describes both the machine and the
treatment using the machine.
2.
WHY USE CPAP?
CPAP was first used to treat babies with breathing problems in the 1970’s. It lost popularity
when mechanical ventilation (also referred to as intermittent positive pressure ventilation IPPV) was invented and was considered to be a superior treatment. Interest in using CPAP
returned in the late 1980’s when it was seen as a potential way of avoiding chronic lung
disease (bronchopulmonary dysplasia, BPD) which had emerged as a complication of IPPV.
As CPAP was known to cause less barotrauma10 than IPPV, it was hoped BPD would occur
less frequently if babies could be treated more with CPAP and less with IPPV.
Research has since confirmed that CPAP reduces the incidence of BPD in preterm babies
(12, 13, 14). It has also proven that:
1. CPAP reduces mortality in preterm neonates (12, 15).
2. CPAP reduces the need for ventilation (IPPV), especially when used early for babies
with HMD (12, 15, 16).
3. Extubating babies from ventilation to CPAP reduces the need for reventilation (12, 15,
17, 18, 19)
4. Using CPAP at nontertiary centres in a developed country setting reduces the need
for up-transfer of neonates with RDS of mixed causes to tertiary centres for ventilation
(20).
These advantages make CPAP attractive for neonatal care in both developed and less
developed countries. The reduction in BPD has been the main motivation for its use in
the developed world where CPAP is increasingly used as first-line treatment for neonatal
respiratory problems, especially for very low birth weight babies (21).
Other features of CPAP make it particularly suited for use in low resource contexts where
staff numbers, monitoring and biomedical maintenance facilities are limited and where other
treatments may not be available due to cost.
3.
CHARACTERISTICS OF CPAP THAT MAKE IT SUITED FOR
USE IN LOW RESOURCE CONTEXTS
CPAP is a simpler technology than IPPV so less training and supervision is required to
10
44
CPAP and the Baby with Difficult Breathing
Barotrauma refers to the lung damage that is caused in IPPV due to the positive pressure inflations.
45
achieve competency in its use11. The simpler technology also means CPAP is cheaper and is
easier to repair than ventilators.
4.
CPAP is also safer to use than IPPV. The baby does NOT need to be intubated so neither
the skills to intubate nor to manage an intubated baby are required by the user. Although
CPAP can be administered to an intubated baby, it is not recommended (see p. 65). In
addition, with CPAP, there is no risk of ventilator associated pneumonia.
These characteristics make CPAP particularly well suited to low resource contexts where,
even when modern ventilators are provided by well intentioned donors, the machines often
fail to be used to potential due to biomedical issues or lack of staff skilled in their use.
CPAP has greater potential than IPPV for safe and successful use in these situations.
Table 9. Important differences between IPPV and CPAP
IPPV
Intermittent positive pressure
CPAP
Constant positive pressure
Technology
More complex
Simpler
Cost
More expensive
Cheaper
Safety
Less safe
Risk of ventilator-associated
pneumonia
Safer
Need
intubation
‘Yes’
No - ‘breathing through a straw’
Ease of use
More complex
Simpler
Ease to repair
More complex
Simpler, fewer parts
WHEN CAN CPAP BE USED?
CPAP is used to treat babies with APNOEA and babies with respiratory
distress.
4.1
CPAP for apnoea
1. CPAP is a proven treatment for apnoea of prematurity (21). However it is
recommended to use CPAP only after a trial of stimulant medication (caffeine or
theophylline) has failed (22). When CPAP is used for apnoea only minimal pressures are
needed unless there is accompanying lung disease. Oxygen may not be needed at all as
the primary problem is immature respiratory drive.
2. CPAP may benefit babies who have apnoea due to rare obstructive causes such
as reduced airways tone (e.g. laryngotracheomalacia) because CPAP increases the
diameter of the upper airway.
3. CPAP may have some benefit in apnoea due to respiratory fatigue. However, in these
babies CPAP is primarily working to alleviate the respiratory distress and the primary
cause of the respiratory distress must also be addressed (see below).
4. If apnoea is severe or recurrent, CPAP is unlikely to be effective. The baby will require
intubation / ventilation and treatment of the underlying cause. This is often the case in
babies who have brain injury (e.g. hypoxic injury, haemorrhage, meningitis) or severe
systemic illness such as sepsis. See ‘relative contraindications’ on p. 49.
4.2
CPAP for Respiratory Distress
1. Respiratory distress is the most common indication for CPAP. There are many
causes of respiratory distress in neonates (see box below) and many babies with these
conditions will respond to CPAP. In practice, CPAP is most beneficial in babies under
35 weeks and the most common indication is hyaline membrane disease (HMD).
11
This should not downplay the importance of close patient monitoring.
46
CPAP and the Baby with Difficult Breathing
2. Meconium Aspiration Syndrome (MAS): Special mention is made of MAS as it is a
common cause of RDS in low resource contexts where obstetric care is often poor, and
because MAS may be difficult to treat. Although some cases of MAS do well with CPAP,
there are many other cases where CPAP is not effective. This may be because:
– Babies with MAS have been asphyxiated so they may have hypoxic ischaemic brain
injury with severe apnoea. CPAP is unlikely to be effective in this situation; the baby
requires intubation / ventilation if available.
– MAS may cause localised areas of lung hyperinflation and this may be exacerbated
by CPAP, particularly if high pressures are used. Hyperinflation may cause hypoxia
and hypotension and can be difficult to manage.
47
–
Babies with MAS may have persistent pulmonary hypertension with severe hypoxia
which does not respond well to CPAP. These cases are very difficult to manage
even in developed countries and treatments such as surfactant lavage, nitric oxide
inhalation and modern ventilation techniques are used. These options are rarely
available in low resource contexts.
3. It may not always be possible to determine the specific cause of neonatal respiratory
distress, particularly when portable X-rays are not available to confirm the diagnosis.
Thus, in practice, CPAP can be tried for any neonate with RDS provided no
contraindications exist.
4.3
Neonatal conditions which may respond to CPAP
–
–
–
–
–
–
–
–
–
Hyaline membrane disease
Apnoea
Pneumonia
Pulmonary haemorrhage
Pulmonary oedema due to cardiac conditions
Aspiration (meconium or other types)
Post-extubation
Transient tachypnoea of the newborn
Airways obstruction due to abnormalities that predispose to airways collapse eg.
laryngomalacia, tracheomalacia
5.
WHEN SHOULD CPAP NOT BE USED?
5.1
Contraindications
1. In tracheo-oesophageal fistula and diaphragmatic hernia CPAP is contraindicated
because it can cause gastric distension which can further compromise respiratory
function. If these babies require respiratory support then they need intubation /
ventilation and other specialised care which is not covered here.
2. In choanal atresia or severe cleft palate the anatomical abnormality makes application of
the CPAP ineffective.
3. In bowel obstruction or necrotising enterocolitis CPAP is contraindicated because it will
exacerbate the gastric distension.
5.2
Situations where CPAP is unlikely to work
There are 3 situations where CPAP is unlikely to work. These are not absolute contraindications however experience has shown that CPAP is often ineffective in these situations.
1. Severe and recurrent apnoea: Babies who have severe or recurrent apnoea have
inadequate drive to breathe to benefit from CPAP (21). This is common in severe
perinatal asphyxia or brain infections.
2. Severe cardiovascular instability: Babies with cardiovascular instability (e.g. severe
sepsis) do not usually do well on CPAP. CPAP often exacerbates the hypotension found
in these situations.
3. Severe and progressive respiratory failure12 : Babies who have very severe lung disease
where oxygen saturations are very low despite high inspired oxygen (eg FiO2 > 60%)
and respiratory distress is very severe may require more support than can be provided
by CPAP.
In these situations, and where the necessary skills and resources are available, intubation
/ ventilation is the treatment of choice. If this is not an option, there is little to be lost in a
closely observed trial of CPAP. However families should understand that the outcome may
not be successful.
5.3
CPAP for older babies
CPAP may also be used for older infants with RDS (especially bronchiolitis or pneumonia),
with airway problems and after extubation. This is not discussed further in this manual as the
focus is on neonatal care.
12
Maybe defined in terms of blood gas analysis as an inability to keep paO2 > 50mmHg, paCO2 <
60mmHg or pH > 7.25 (20, 22)
48
CPAP and the Baby with Difficult Breathing
49
6.
HOW DOES CPAP WORK?
CPAP works by providing a constant pressure, with a variable amount of
oxygen, to the airway of a spontaneously breathing patient.
When a baby being treated with CPAP breathes OUT, the pressure generated by the
machine helps to keep the baby’s alveoli and small airways open and prevents them from
‘collapsing’. In technical terms, functional residual capacity (FRC) of the lungs is maintained.
This increases the amount of lung which is available for gas exchange13 and is the main way
that CPAP improves breathing.
CPAP has additional effects on the alveoli and other components of the respiratory system
which also improve a baby’s breathing (23).
– splinting open the upper airway
– protecting surfactant (24)
– reducing the amount of fluid (oedema) in the alveoli
– stabilising the chest wall (25)
– stretching the lungs and pleura
– allowing more blood to flow through the lungs14
These effects all work towards
– increasing blood oxygen
– reducing the work of breathing and
– reducing apnoea
7.
HOW IS CPAP GIVEN?
CPAP can be given either via a conventional ventilator (which has both regular ventilation
and CPAP modes) or via a stand-alone CPAP device. There are 2 main types of stand-alone
CPAP devices:
7.1
Pressure driven CPAP
These machines use a constant flow of gas and another mechanism determines the
pressure. The user sets the pressure. A common type of pressure driven CPAP is known
as ‘Bubble CPAP’; so called because bubbles are created when the baby breathes out and
the expired gas enters the water out the end of the expiratory limb of the CPAP circuit (see
diagram p. 61).
7.2
Flow driven CPAP
These machines use changes in the flow of gases to determine how much pressure is
generated. The user sets only the flow rate. These machines tend to be more expensive than
bubble devices and require more technical expertise to operate. They may be slightly more
effective for some conditions. They are not described further in this manual.
The EMW CPAP machine is an example of bubble CPAP. How it works is explained in detail
on the following page.
CPAP improves oxygenation, reduces the work of breathing and reduces
apnoea.
13
14
reduces ‘ventilation perfusion mismatch’
reduces pulmonary vascular resistance
50
CPAP and the Baby with Difficult Breathing
51
8.
HOW DOES THE EMW CPAP MACHINE WORK?
Here is a simplified explanation of how the EMW CPAP works. As this manual is meant
for use by a wide variety of health workers, technical terms have been kept to a minimum.
Further biomedical detail for engineers can be found in the EMW biomedical maintenance
manual.
Air compressor
The air compressor is a pump which extracts air from the atmosphere by suction and drives
it into the CPAP machine at pressure (400kPa). The air is cleaned by a filter and then
travels from the compressor to the blender. The air compressor requires electricity to work.
In case of power failure the pump will not work and no air will be supplied to the CPAP
device15 .
The diagram illustrates the EMW CPAP device and names its main components. The
purpose and function of each of the components is briefly described. The parts are
described in-series, beginning with the gas compressor. The control box is described last. A
block diagram illustrates the functional circuit of the CPAP system.
8.1
1.
2.
3.
4.
5.
6.
7.
Main parts of the CPAP machine
Air compressor
Blender
Expiratory / pressure bottle
Inspiratory / heating bottle
Front panel of control box
Back panel of control box
Patient circuit
Blender and gas flows
The blender controls, measures and mixes gas flow before it is sent through the CPAP
system. It receives gas from the air compressor and from the external oxygen supply. An
oxygen source is NOT part of the CPAP device and must be provided separately. This is
discussed later (p. 62).
There are 2 separate compartments inside the blender, one for the air and one for the
oxygen. Each chamber has a separate flow meter (air on the right, oxygen on the left) which
can deliver flow from 0-10L/minute. However combined flow rates of more than 8L are rarely
used. The flow meter contains a ‘ball float’ which rises up as the flow valve is turned on.
The set flow is measured by the level of the middle of the ball float against the markings on
the side of the flow meter. The user determines how many litres of air and of oxygen will be
provided.
15
In this situation 100% oxygen will still be supplied because the oxygen supply is not reliant on
electricity.
52
CPAP and the Baby with Difficult Breathing
53
The gases are mixed (‘blended’) and leave via the common gas outlet (a thin clear plastic
tube) on the back side of the blender. The common gas outlet takes the gas into the
‘inspiratory bottle’.
On the front of the blender there is a table which tells the user what concentration of oxygen
(FiO2) is being delivered when differing combinations of flows of oxygen and air are set.
The proportion of oxygen vs air in the mixed gas determines the FiO2. The user selects
both the oxygen concentration and the flow rate he wishes to use, eg. 3L oxygen and 3L
air provides a FiO2 of 61%; 5L oxygen and 1L air provides FiO2 of 87% etc. There are
exercises on this later in the manual (p. 121).
Figure 8. back of the blender
Inspiratory / heating bottle
The inspiratory bottle is the bottle which sits in the posterior ring of the metal hanger on
the left side of the CPAP device. The metal plates surrounding this bottle contain heater
elements. This heats the water in the bottle according to how much ‘heat’ is set by the user.
Heat is set with the ‘humidity knob’ on the front of the control box (for the first 45 minutes
54
CPAP and the Baby with Difficult Breathing
55
after the CPAP is turned on, the amount of power delivered to these heater elements is
set to 100%. After this, the heat can be set from 45-70%); see below. Increasing the heat
increases the humidification of the gas. Gases enter the inspiratory bottle via the common
gas tube which enters the lid of the inspiratory bottle.
The force of the gas flow entering the water creates bubbling in the bottle. The gas picks
up both heat and moisture as it passes through the water – so the gas leaving the bottle is
heated and humidified16 . The gas leaves the inspiratory bottle through a hollow metal tube
which is not submerged in the bottle and which comes out through the lid.
16
The inspiratory bottle could equally be called the heater bottle or the humidity bottle
56
CPAP and the Baby with Difficult Breathing
Patient circuit
The patient circuit is the long light blue corrugated silicone tubing which connects the
CPAP bottles to the patient interface at the baby’s nose. There are 2 ‘arms’ to the circuit,
inspiratory and expiratory.
57
The inspiratory arm arises from the hollow metal tube in the inspiratory bottle. It carries the
gas from the inspiratory bottle to the ‘interface’ at the baby’s nose. Inside the inspiratory arm
there is a thick black wire. The wire is a ‘heating element’ that is plugged into the back panel
of the control unit. The temperature of the wire is determined by the ‘set temp’ knob on the
front of the control box. There is a sensor at the end of the wire, close to the baby’s nose.
The sensor measures the temperature of the gas at this point and transmits this information
back to the CPAP control box. The measured temperature is displayed on the lower LCD
screen on the front of the control unit. When the measured temperature reaches the set
temperature the CPAP automatically reduces the heating to the wire. If the temperature at
the sensor is too high, the CPAP will alarm and will automatically reduce the set temp (see
below, alarms section). This mechanism helps protect the baby from exposure to overheated
gases and reduces condensation of water in the tubing.
Patient interface
This is not part of the CPAP device. It is a separate unit and is discussed below. It transmits
the gas from the inspiratory arm of the circuit INTO the baby’s airway and transmits the
gases that the baby breathes OUT back into the expiratory arm of the circuit. It is described
in the next section.
Expiratory / pressure bottle
The expiratory bottle sits on the most anterior of the 2 metal rings on the bottle holder (the
ring without any heating plates). The expiratory bottle is differentiated from the inspiratory
bottle by the centimeter markings on the side of the bottle.
The baby’s expired gas enters the expiratory bottle through a hollow metal tube which
connects to the expiratory circuit above the bottle lid. As the baby expires, gas enters the
water and bubbles are formed. The depth of the metal tube in the bottle determines the
pressure provided by the CPAP (this is also called end expiratory pressure) which supports
the baby’s breathing. For example, if the leg is submerged to 7cms then 7cms H20 of
pressure is being delivered. The deeper the tube is submerged the greater the pressure
provided to the baby. Expiratory gases escape from the water to the atmosphere through a
small hole in the lid of the bottle.
58
CPAP and the Baby with Difficult Breathing
Control box
The control box is the electronic part of the CPAP device. It contains the user controls,
display screens and alarms.
Front panel
The front panel has 2 display screens, an on/off switch, 2 control knobs and 2 alarm
buttons.
59
Controls
The 2 controls need to be set by the user. These include:
connections for the air compressor and additional power outlet, diagnostic buttons for use
by biomedical engineers who are servicing the machine, power supply cord and fuse.
1. ‘Set temp’. This knob determines the temperature of the inspired gas by heating the wire
inside the inspiratory arm of the patient circuit. The possible set temperature ranges
between 35 and 39oC. The set temperature is shown in red in the top LED screen.
2. ‘Humidifier’. This dial determines the amount of heat output (45 – 70%) supplied to the
heater elements next to the inspiratory bottle. The set amount of heat is shown by the
LED display column immediately above the dial. Note that whilst the CPAP is warming
up (for the first 45 minutes after turning the CPAP on) the heat output to the humidity
heater elements is fixed (cannot be changed) to 100%. Increasing the heat increases
humidification of the gases.
LED displays
The top display shows the set temperature between 35 and 39oC. The bottom display has
2 lines. The upper line shows the temperature recorded at the sensor in the metal wire hose
inside the inspiratory circuit arm. The measured temperature is displayed as ‘Sensor: XXoC’
in blue. The second line shows the amount of power the heater is using to provide in order to
reach the set temperature. It is expressed in %, from 0 to 100%. For example, if the CPAP
has just been switched on the heater output will be 100% as it tries to heat up quickly to
reach the set temperature. When the heater reaches the set temperature the heater output
will begin to drop below 100%. The heater output power will then constantly fluctuate as
it tries to maintain the temperature at the required level. This is normal. It may also drop in
alarm conditions, see below.
Figure 9. Back panel of the CPAP
The block diagram illustrates the circuit of the CPAP as is described in text above17.
Alarms
There is one audible and one visible alarm on the top of the front panel. The alarm on the left
side is the ‘visible alarm’. It flashes for an alarm condition.
The button on the right side controls the ‘audible alarm’. The audible alarm can sound
only when the right side button is pushed IN. The audible alarm sounds (beeps) for a few
seconds when the machine is first turned on. It also sounds whenever an alarm condition
occurs and the left hand alarm is flashing. If the button is OUT the alarm is muted.
Alarm conditions include:
1. the heater wire / sensor is disconnected
2. the sensor in the inspiratory arm records a temperature that is too high or too low
See later (p. 98) for further explanation.
Back panel
The back panel has the connection for the heater element wire of the inspiratory circuit, the
60
CPAP and the Baby with Difficult Breathing
Figure 10. CPAP circuit
17
Diagram developed and provided by Mr Bruce Morrison
61
8.2
Oxygen supply
An oxygen source is not part of the EMW CPAP device. A separate oxygen supply must be
provided and connected to the CPAP. Oxygen is connected to the CPAP device via the blue
hose which enters the back of the blender.
THERE ARE 3 OPTIONS FOR PROVIDING OXYGEN TO THE CPAP
Oxygen from a cylinder
Wall outlet oxygen and
Oxygen from an oxygen concentrator
Oxygen concentrators
These are economic and portable devices which, in a similar way to the CPAP air
compressor, extract oxygen from the atmosphere. Oxygen concentrators can provide oxygen
in flow rates up to 8L/minute which is sufficient for the vast majority of neonates who require
CPAP.
It may not be adequate for an older infant. The oxygen concentrator is a low pressure oxygen
system so no regulator is required. The oxygen hose of the CPAP machine will need to be
connected to the flow meter outlet of the oxygen concentrator and compatible connections
are again required. The humidifier on the oxygen concentrator could be removed when
connecting the CPAP as the humidifier is built into the CPAP. The oxygen concentrator
requires electricity in order to function. Therefore it is good practice to have a back-up
oxygen cylinder / regulator close by in case of power failure.
Oxygen from a cylinder
Oxygen provided from a cylinder is the most common scenario in low resource countries.
The oxygen cylinder must be fitted with a medical oxygen regulator. The regulator sits
between the oxygen cylinder and the CPAP machine. The regulator is also known as a
‘reducing valve’ because it reduces the pressure of the gases inside the cylinder to allow
the flow of gas to be controlled (9). When attaching the CPAP to the oxygen cylinder,
you will need to ensure the end of the CPAP oxygen hose and the regulator connection
are compatible. If not, they won’t join and another solution will need to be found18 . Never
connect the CPAP to the oxygen cylinder without a regulator. When using an oxygen
cylinder a spare cylinder must always be available.
Oxygen from a wall outlet
This will usually only be found in larger hospitals as it is a costly instillation and requires a
lot of maintenance. Where wall oxygen is available the oxygen hose from the CPAP screws
directly onto the wall outlet. In wall oxygen set-ups the oxygen outlet is regulated to 400kPa.
A separate regulator is not needed. As with the cylinder set up, the CPAP oxygen hose and
the wall outlet connectors must be compatible.
Figure 11. A typical oxygen concentrator
Much more detailed information regarding oxygen supplies and systems, for
clinicians, administrators and biomedical engineers alike, can be found in
the recent publication The Clinical Use of Oxygen in Hospitals with Limited
Resources. Guidelines for health workers, hospital engineers and program
managers (WHO 2009).
Note: if oxygen is not provided or available, the CPAP device will still function however it
can provide only air. This may still be effective for treating apnoea of prematurity however the
majority of cases treated with CPAP need oxygen as well as pressure support.
18
Contact MTTS BME to discuss if there is no locally available biomedical expertise to solve the
problem.
62
CPAP and the Baby with Difficult Breathing
63
8.3
Patient Interfaces
The patient interface is the part that connects the baby to the CPAP circuit. It transmits
the gas from the inspiratory arm of the circuit INTO the baby’s airway and transmits the
gases that the baby breathes OUT back into the expiratory arm of the circuit. Several
different patient interfaces are available. Each device, together with its advantages and
disadvantages for use, is depicted in table 10. They are discussed in turn.
Cut ETT
A cut ETT is the cheapest interface and is therefore the most practical option in low
resource countries. It is also the most secure interface because a reasonable length is
inside the nose. A disadvantage is that it may exacerbate secretion production, especially
after it has been in for a few days, so tube care is particularly important. It can be less
comfortable for the baby than softer shorter nasal prongs. How to prepare, insert and fix a
cut ETT is shown on p. 109. A single ETT can be cut into 2 or 3 smaller lengths to enable
2-3 uses. Note, it is very important that the ETT is cut to the correct length. An uncut ETT
must NOT be used, the ‘resistance to breathing’ is too high and work of breathing is greatly
increased.
with secretion production compared with longer prongs. However, these devices may not
be affordable or readily available in low resource contexts. Commonly used brands include
Hudson, Argyle and Inca prongs. Images are included in the table. An example of how to
insert and fix nasal prongs is shown on p. 112.
Fitted nasal face masks
Soft fitted nasal face masks have been developed for neonatal CPAP in order to try to
reduce nasal trauma, so often a complication of nasal prongs. These masks are effective
however it can be difficult to maintain a seal. In addition they are costly and as yet not
available in low resource contexts.
Endotracheal tube
CPAP can be administered through a regular ETT (i.e. to an intubated baby). This method is
sometimes used when testing to see whether a ventilated baby is ready for extubation. The
ETT is left in place; the baby is switched from ventilation to CPAP. The baby is observed
before deciding whether to extubate to nasopharyngeal CPAP or to return to ventilation.
Providing CPAP through a ETT however has 2 serious problems. Firstly, breathing through
a long ETT is very difficult for the baby. As mentioned above, the resistance of breathing
through a long tube is very high, so work of breathing will be increased. The second and
VERY IMPORTANT issue is that, in case of tube blockage, the baby has no alternative
airway; tube blockage may result in severe hypoxia and / or death.
ETT CPAP should ONLY ever be used as a very temporary measure (for
a few minutes only) and it is essential that the baby has CONTINUOUS
nursing observation throughout that period in case of tube obstruction.
Protocols on how to connect, apply and how to care for each of these interface devices are
found in the section on patient care.
Correct
Incorrect
Nasal prong devices
CPAP with nasal prongs has been shown to be more effective than CPAP delivered through
a single nasopharyngeal tube (cut ETT) (26). As the prongs are short, there is minimal
resistance to flow so pressure is transmitted more effectively to the lungs. Various devices
are available. Each is designed with an adaptor to allow them to connect to the CPAP
circuit. Many also come with fixation devices such as caps, velcro tapes and ties. Fixation
is the biggest ‘disadvantage’ of these devices. As the prongs are only inserted into the
anterior part of the nares it is easy for them to dislodge. Once the prongs are dislodged the
CPAP is ineffective. The prongs may also cause nasal trauma. There are fewer problems
64
CPAP and the Baby with Difficult Breathing
65
Table 10. Patient interfaces
Advantages
Disadvantages
-Cheap
-Availability
-Securest fixation
-Exacerbates secretions so
obstruction a common problem
-Easy to kink
-Nasal trauma
-Significant leak through other
nostril
-Tape can cause skin trauma on face
Nasopharyngeal tube (cut
ETT)
Double nasal prongs
- Hudson prongs
- INCA prongs
9.
HOW TO USE CPAP – MEDICAL AND NURSING PROTOCOLS
9.1
When to start CPAP
CPAP SHOULD BE CONSIDERED IN THESE SCENARIOS
A preterm baby (<35wks, 1800g) who has recurrent or severe apnoea
that does not respond to stimulant medications.
A term baby who has recurrent apnoea.
A baby (term or pre-term) with respiratory distress unable to keep
saturations > 90% (9, 20) on maximal oxygen flows via non-invasive
means (p. 31).
A term baby with respiratory distress due to probable meconium
aspiration or pulmonary hypertension or sepsis unable to keep
saturations >94% on maximal oxygen flows via non-invasive means (9,
20).
-Probably the most effective
device
-More comfortable for the
baby
-Difficult to secure; require quite
complex fixation devices.
-Expensive
-Nasal trauma
After extubation in very low birth weight neonates.
Assuming the baby has no contraindication to CPAP (p. 49).
Additional points
Preterm babies
- Argyle prongs
1. A lower oxygen requirement is recommended for starting CPAP in preterm babies
because research has shown that babies with HMD do better when CPAP is begun
early in the course of their disease (21). Fewer babies later require intubation and
ventilation. Beginning CPAP early prevents further lung collapse which is difficult to
reverse once established.
Fitted face mask
-Minimal nasal trauma
-Difficult to maintain a seal
-Cost / unavailability in low resource
contexts
-None to justify
recommending its use
-Difficult for baby to breathe through
due to small diameter
-If obstructs, no alternative airway
available
-NOT RECOMMENDED.
ETT
66
CPAP and the Baby with Difficult Breathing
2. Using the same logic, some neonatal units in the developed world use prophylactic
CPAP in very small (< 1kg) babies who are at high risk of developing HMD. CPAP is
initiated at birth, before they have signs of RDS. There is no good evidence that this
results in better outcomes and there is some concern about potential side effects from
the CPAP (27). It is not recommended in low resource contexts (23).
3. Surfactant has revolutionised the outcome of babies with RDS over the past 20 years.
It reduces the need for ventilation, reduces the incidence of pneumothorax and reduces
mortality in preterm babies with RDS (28). Neonatal units in the developed world
routinely administer surfactant to preterm babies with RDS. It is used either as treatment
67
for babies with established RDS and an increasing oxygen requirement (e.g. > 40%)
or, prophylactically, for babies at risk of severe disease (e.g. < 27-30 wks gestation).
Many units use a strategy called ‘INSURE’ which is a combination of surfactant and
CPAP. Babies at risk of severe disease19 are intubated, given surfactant and then
quickly extubated to nasopharyngeal CPAP. This has been shown to reduce the need
for ventilation (28). However economic constraints seriously limit the availability of
surfactant in low resource contexts so hospitals must determine their own policies
regarding use. Surfactant is not discussed further in this manual.
9.2
How to start CPAP
CHECKLIST FOR STARTING CPAP
Get the CPAP machine and check it is ready for use (p. 96)
Turn it on and dial the machine settings you want to use
Prepare the tube / prongs (p. 109)
Bigger babies
RDS in bigger babies is rarely due to HMD and the criteria for when to start CPAP for nonHMD RDS are less clearly defined. Some causes of RDS in bigger babies, such as TTN,
may resolve spontaneously even if oxygen requirements increase beyond 30%. In addition,
bigger babies do not tolerate CPAP as well as smaller babies. Therefore a higher oxygen
threshold (e.g. requires FiO2 > 50%) is suggested for starting CPAP in these babies.
Prepare the baby (p. 103)
Insert the tube / prongs and attach the baby to the CPAP.
Remain with the baby and observe the baby’s response to CPAP.
Ventilation
Adjust the settings if needed (p. 104)
This manual does not attempt to cover neonatal ventilation however some hospitals that
provide CPAP will also have ventilators. In these hospitals, CPAP criteria will need to be
modified to take into account the option of ventilation. One of 2 approaches can be used:
If possible, get a portable CXR* and do an ABG**.
1. Try CPAP in all cases of RDS using the above criteria. Stop CPAP and intubate /
ventilate only if CPAP fails (p. 75).
OR
*A CXR is useful to confirm the underlying cause of the RDS however availability will determine use.
**ABG is only recommended if ventilation is also available and if ABG results are used to determine when to
stop CPAP and to use IPPV.
Table 11. Suggested start settings for CPAP for various conditions
2. Choose to intubate / ventilate from the outset babies who have particularly severe RDS
(e.g. severe RDS and FiO2 > 70%) who are unlikely to respond to CPAP.
The decision will depend upon various factors including staff skills, staff numbers and
patient load. When blood gas analysis is available, pCO2 and pH may also be used to guide
the decision of when to choose ventilation (e.g. unable to maintain paO2 > 50mmHg and /
or paCO2 > 60mmHg) (13, 23).
CXR
If CXR is available this may assist in confirming the cause of the RDS and the severity of
HMD. CXR is not needed prior to starting CPAP unless there is strong clinical suspicion of
congenital diaphragmatic hernia, tracheo-oesophageal fistula or pneumothorax.
19
Generally this would include babies < 28-30 weeks of gestation.
68
CPAP and the Baby with Difficult Breathing
APNOEA
HMD
Non-HMD
Bigger baby
Post ventilation
Pressure
5cm
5cm
6cm
5 or 6cm
Oxygen*
21-30%
50%
50%
30%
Flow
~6L/minute combined flow (oxygen + air ~ 6L)
(choose a combination of flows to give the desired FiO2)
Humidity
50% - in dryer climates set at 80%
Set temperature
36 – 37.5oC
These start settings are a guide only. Although they may suit many babies, it is imperative
that the doctor and nurse remain with the baby to observe the baby’s immediate response
to the CPAP. They must decide whether the baby is responding and whether the settings
require adjustment.
*The recommended start FiO2 levels are very empiric. On very sick babies you may begin
with 100%. This is acceptable as long as you remain with the baby to reduce the FiO2
69
towards the more appropriate level according to saturations (p. 76). Babies with apnoea
may not any supplementary oxygen.
9.3
How to care for babies being treated with CPAP
Immediate response
4. IF ventilation is an option it should be considered for babies who require > 8cms
pressure, FiO2 > 70%. If ABG analysis is available this may help to decide when to use
ventilation (e.g. unable to maintain paO2 > 50mmHg, paCO2 > 60mmHg, pH < 7.25)
(21). However ABG analysis is rarely readily available as to be useful for decision making
in low resource contexts.
9.4
Regular patient monitoring
Whether CPAP is helping the baby is usually apparent within half an hour.
Clinical signs that:
Parameter
CPAP is working
CPAP is not working
SpO2
Improves to normal range
Respiratory rate
Reduces towards normal
Respiratory effort (retractions,
grunt, flare)
Reduces or none
Pulse rate
Reduces towards normal
Peripheral perfusion
Improves / warms
General condition
Calm, less agitation
Restless, agitated
Desaturations and apnoea
None or fewer than before
starting CPAP
Same number or more than
before starting CPAP
No change or worse, even if
increase FiO2
The baby who is not responding
If the baby is not improving after starting CPAP, check the machine is set up correctly and
the connections are intact (p. 96). If everything is in order then cautiously increase the
CPAP support:
1. Oxygen (FiO2) can be increased in increments of 5%. If FiO2 of 60% or more is
required to maintain SpO2, the baby has severe hypoxia.
2. Pressure can be increased in 1cm increments to a maximum of 8cms20 .
3. Increasing flow in increments of 1L/min may improve ventilation.
Although CPAP is simpler to use than IPPV, this does not mean that babies on CPAP should
receive less vigilant care. CPAP is an intensive care treatment.
Babies on CPAP may deteriorate at any time due to their underlying respiratory problem
or due to a complication of CPAP. Complications, in particular pneumothorax and tube
blockage, may occur suddenly and catastrophically.
Adhering to the care principals outlined here will reduce the likelihood of these occurrences.
The baby – what to monitor
1.
2.
3.
4.
5.
6.
7.
8.
Vital signs - SpO2, RR, HR
Respiratory effort (retractions, grunting, flaring)
Peripheral perfusion (colour, warmth, BP #, urine output)
Secretion production
Nasal skin for redness
Abdominal distension
Feed tolerance
Level of comfort, assuming appropriate sized BP cuffs available
–
–
Observations should be recorded on the patient monitoring form (p. 120).
The frequency of patient monitoring depends upon the patient’s condition and should be
specified by the doctor.
Ideally, vital signs should be CONTINUOUSLY monitored. However, in reality,
continuous electronic patient monitoring may not be available. If this case, every attempt
should be made to monitor vital signs hourly, at least during the first 6-12 hours and
during periods of instability.
–
Neither increasing pressure or flow should be done if the baby may have hyperinflation.
After making alterations to the settings
Alterations in patient observations will alert the staff to the possible
presence of complications.
1. Obtain a portable CXR if possible.
2. Continue to observe until stable (see patient monitoring below).
3. Ensure all measures are being taken to calm the baby and make the baby comfortable
(p. 78).
20
In bigger and/or older infants higher pressures may be considered up to 10cms however the baby will
need careful monitoring, both clinically and by CXR, for signs of hyperinflation.
70
CPAP and the Baby with Difficult Breathing
71
CPAP – what to monitor
Troubleshooting the machine
Problem
Possible reason
What to do
No bubbles in
expiratory bottle
Gas turned off or disconnected.
A leak in the system – a bottle
lid is not sealed or a tube
disconnected.
Baby apnoeic.
Large leak out baby’s mouth
(mouth open).
Disconnect the baby from the CPAP
and occlude the circuit with your palm.
If bubbling returns, then the problem is
with the baby (apnoea or mouth leak).
If there is still no bubbling it is a
machine problem. Check the gas
flow is ON. Tighten the bottle lids and
check the circuit connections.
Heater wire disconnected.
Electrical malfunction.
Ensure the tube-set is connected
properly to the CPAP unit.
Try changing the heater wire.
If this doesnt fix it, change machines
and call BME.
The sensor in the patient circuit
measures a temperature > 40
O
C. This may be due to excess
external heat eg from a radiant
warmer, or due to machine
malfunction.
Disconnect the patient (provide CPAP
with bag/mask if needed or swap to
another CPAP unit and circuit). Turn
off the CPAP for 10 minutes and
check if the sensor cools down (hold
under a fan or AC if available). If the
sensor cools, reconnect the baby and
try to use the CPAP again. Observe
carefully. If the problem recurs,
change to another machine and report
the problem to BME.
No gas flow detected
Check gas is on.
Check for leaks in the circuit (air
compressor, oxygen supply, common
gas tubing). Fix any disconnections or
kinks in circuit.
If problem continues, change machine
and inform BME.
Machine settings – pressure, FiO2, flow - are they as ordered?
Circuit connections – are they correct and intact?
Oxygen level – is the cylinder approaching empty?
Water - Does it need filling? Is it bubbling?
Humidity – is there water droplets in the tubing to empty?
ALARMS
display says “sensor
off and no tubeset!!”
Temperature reading – is the reading close to the set temp?
Alarms – is the alarm light on?
–
–
–
–
Equipment checks can be done at the same time as patient observations.
Equipment checks should also be recorded on the patient monitoring form
They should be done at least 4 hourly but it is preferable to check each time patient
observations are performed.
Equipment checks can be done very quickly with practice.
ALARMS
display says ‘check
temp sensor’ or
‘check set temp’.
Checking equipment and responding to problems early will prevent later
complications and problems with the baby.
ALARMS
display says ‘no flow’.
Monitoring frequency
The main objective of regular patient monitoring is to detect and respond to problems early
so to prevent more serious complications from occurring.
–
–
72
CPAP and the Baby with Difficult Breathing
In low resource contexts, human resources may be insufficient relative to the number of
sick babies. The ideal frequency of monitoring may not be possible as nurses are too
busy.
There needs to be a balance between what is safe and the reality. Hospitals who commit
73
–
to offering CPAP must be responsible and ensure a minimum nurse ratio for safe patient
care.
Monitoring frequency will vary a little according to how unwell the babies are.
A ratio of 1 nurse to 3 CPAP should be the ABSOLUTE maximum patient
load. With this ratio patient observations can be performed 1-2 hourly.
9.5
When to call the doctor
A nurse should call for medical assistance when he / she is concerned a baby has
deteriorated or may have a problem that needs medical attention. The following list is a guide
of specific circumstances when a doctor should be notified. It cannot cover every possibility;
a good principal is, if you are worried or unsure, then call.
Baby problem
1. A need to increase FiO2 > 10% or more in a 4 hour period
2. SpO2 < 90% even after increase FiO2 by 10%
3. More than 3 apnoeas, or 1 apnoea that does not respond to stimulation and requires
bag / mask ventilation
4. Concern the baby has a pneumothorax (sudden deterioration in respiratory status)
5. Abdominal distension or feed residuals (more than 25% of feed or bile) or vomiting
6. Signs of inflammation of the nose
7. Bleeding from the nose
Machine problem
1. No bubbling in expiratory bottle and cannot resolve it with simple measures
2. Concern that the tube needs to be changed21
3. Any concern about the CPAP machine (alarm situations)
21
In some hospitals nurses may change the nasal tube independently; this needs to be a policy decision
at local level and will depend upon the skills of nurses, the number of nurses and how sick the individual baby
is.
74
CPAP and the Baby with Difficult Breathing
75
9.6
Regular patient care
This section describes the medical and nursing aspects of care which are important when
a baby is being treated with CPAP. For medical issues not covered in detail here refer to
Managing Newborn Problems, WHO 2003 and other standard textbooks of neonatology.
Several of the areas addressed here are also formatted into bedside job aides later in this
chapter p. 95.
Oxygen saturations (SpO2)
Adjusting the pressure during CPAP is a medical responsibility. However, adjusting the FiO2
is a medical and a nursing responsibility as changes may have to be made often.
Oxygen saturation monitoring is very important during CPAP, especially for preterm babies
(especially those < 32 weeks or < 1250g) who are at risk of retinopathy of prematurity
(ROP). ROP is a disease of the retina which is caused by high blood levels of oxygen.
ROP may cause irreversible eye damage and blindness. In developed countries, all preterm
babies who receive oxygen therapy will be checked by an ophthalmologist who can detect
and treat ROP with laser therapy if needed. These services may not be available at all in low
resource contexts so every effort possible must be made to prevent ROP.
ROP is prevented by trying to prevent hyperoxia, by strictly monitoring and maintaining
SpO2 levels within the ‘safe range’.
SpO2 for preterm babies should be maintained between 85-93% at all
times. Oxygen saturation monitor alarm limits should be set to reflect this:
set lower limit 83% and upper limit 95% (8).
Preventing ROP implies that SpO2 monitoring is available
If SpO2 monitors are unavailable then this becomes an impossible task. Clinical assessment
cannot detect or prevent hyperoxia. It can be argued that CPAP should not be used where
frequent SpO2 monitoring (at least hourly) is not possible.
Term babies (35 weeks or more) are not at risk of ROP. SpO2 need not be so tightly
controlled. However unnecessarily high oxygen levels should still be avoided as there may
be other side effects of too much oxygen and it is wasteful of oxygen. SpO2 should be
maintained > 95% but oxygen should be weaned if SpO2 is >/= 98%. If a baby may have
pulmonary hypertension (e.g. MAS and severe hypoxia) then saturations should be kept
higher, preferably > 97% (10).
76
CPAP and the Baby with Difficult Breathing
In term babies SpO2 should be kept > 90%. If a baby is thought to have
pulmonary hypertension, sepsis or asphyxia then they should be kept >
95%.
Medications
There are no medications that are needed just because a baby is on CPAP. Medications are
determined by the medical reason for the CPAP; ie by the underlying disease. In practise, all
babies with RDS on CPAP should be treated with antibiotics (Ampicillin and Gentamicin), at
least until infection can be ruled out. This is because it is difficult to exclude pneumonia as
the cause of RDS and, in low resource contexts, microbiology may not be readily available
or of reliable quality. Nystatin should be used if the babies are on antibiotics. Babies with
apnoea should be treated with IV aminophylline or caffeine, depending on availability (p. 18).
Paracetamol may be used for fever or pain (see below). See Managing Newborn Problems,
WHO 2003 or The Pocket Book of Hospital Care for Children (WHO 2005) for standard
neonatal drug doses.
Sedative drugs should NOT be used for babies on CPAP because sedatives
may depress respiratory drive.
Feeding / fluids
Babies on CPAP should be fed providing it is medically safe to do so (see below).
Feeds should be given 2-3hrly via orogastric tube (OGT) depending on the baby’s size.
Refer to Managing Newborn Problems, WHO 2003 for recommended feeding regimes
for sick neonates. Providing feeds in the recommended regimen will also help prevent
hypoglycaemia which can cause apnoea and deterioration in a baby’s condition.
If the baby does not tolerate the OGT (keeps trying to expel it with his tongue), then a
nasogastric tube can be used. OGTs are preferred because babies are ‘obligate nose
breathers’ (they prefer to breathe through their nose), so if one nostril is occluded with a
CPAP tube then it is better to leave the other unoccluded.
If a baby cannot be fed then IV fluids must be provided. Again, refer to Managing Newborn
Problems, WHO 2003.
A baby on CPAP should not be fed if:
– Severe or worsening RDS – FiO2 > 60%, severe retractions
– Moderate or severe ‘CPAP belly’ and / or more than 2 gastric aspirates of > 25% of the
previous feed or bile stained gastric aspirate
– Other GI complication such as GI bleeding or vomiting
– Anticipating a trial off CPAP in next 4 hours
77
Patient comfort
Patient comfort is important. If a baby is uncomfortable on CPAP it is distressing for
everyone. Equally importantly, if the baby is unsettled it will interfere with oxygenation, the
CPAP may be less effective, more secretions are produced and there is a greater risk of
pneumothorax.
Reasons a baby may appear uncomfortable include:
– pain
– hunger
– fever
– hypoxia / worsening respiratory status
Fever
Fever is easily checked. If febrile, the baby should be examined to determine a cause for
fever. Antibiotics may be required and paracetamol can be given to help reduce the fever
and improve comfort. Fever may be caused by external heating devices. If a baby is under a
warmer, reduce the set temperature.
3. Offer a dummy which may be dipped in milk, nystatin or sucrose solution. A dummy may
also help reduce any CPAP leak via the mouth. The top ‘half’ of the dummy support may
need to be cut in order for it to fit in the mouth and ‘below’ the nose with the nasal tube
in-situ.
4. Kangaroo Mother Care (KMC) can be used provided the baby is stable and the oxygen
requirement is not very high (e.g. < 40%). KMC will also assist in maintaining breast milk
supply and may make the parents feel more involved in their baby’s care.
Care of the nose
Care of the nose is a very important part of nursing care on CPAP because the nostril may
be damaged by pressure from the nasal tube or prongs. This is most likely when a tube is
tied incorrectly or is changed infrequently. It may also occur if prongs of incorrect size are
used (i.e. too large) or if they are badly positioned.
Pressure from the tube/prongs can cause inflammation and may result in skin breakdown.
Bacteria may enter through damaged nasal skin and may result in local or systemic sepsis.
Skin damage may result in permanent nasal deformity.
Hunger
If a baby cannot be fed for medical reasons, sucking a dummy dipped in sucrose solution22
may calm him. If the baby is being fed, check to see whether a feed is due and that the
feeds being prescribed are of adequate volume.
Hypoxia / worse RDS
Hypoxia can be checked with SpO2. If the baby has hypoxia, turn up the oxygen 5%. If there
are signs of worsening respiratory status, check the machine and circuit and check the baby
for signs of complications (p. 84). Use the protocol to check for a cause and to start to treat
the problem.
Pain
A doctor should check the baby for sources of pain (e.g. abdominal disease, pressure
sores). If a cause is found then treatment specific to the cause should be given.
Paracetamol may be given for analgesia. The dose is 15mg/kg by OGT or rectally, up to 4
times per 24 hrs (6).
If none of these things appear to be the cause of the discomfort then the baby should be
managed with the following simple interventions, each of which may help:
1. Swaddling with firm wraps
2. Nesting
22
To make sucrose solution mix 33g of sugar with 100ml of heated drinking water (sterile water) and stir
until dissolved (http://www.livestrong.com/article/284024-how-to-prepare-sucrose-solutions/). Do not store
the solution beyond 24 hours as it is an ideal medium for bacterial growth.
78
CPAP and the Baby with Difficult Breathing
A
B
C
Figure 12. Nasal erosions caused by CPAP patient interfaces
Accessed on-line fn.bmj.com. Original in Fischer C, Bertelle V, Hohlfeld J, Forcada-Guexl M, StadelmannDiawl C, Tolsal J. Nasal trauma due to continuous positive airway pressure in neonates. Arch Dis Child Fetal
Neonatal Ed doi:10.1136/adc.2009.179416
Good nursing care can prevent this complication. Care must be taken to ensure the tube
is tied and changed according to protocol (p. 104), that the correct sized prongs are used
and that prongs are positioned correctly (p. 109). If any redness is seen on the nostril during
patient observations, the tube / prongs should be removed. If using a single nasal tube,
move it to the opposite side. If using prongs, check they are the correct size and reposition
carefully, ensuring no pressure on the nares. Topical antibiotic ointment may be used for skin
breakdown to try and prevent infection.
Suctioning
Suctioning is another important part of nursing care on CPAP. Appropriate suctioning will
79
help to prevent tube blockage and subsequent deterioration. However, suctioning is not
without risks to the baby. Suctioning may upset the baby. It may cause bradycardia and
desaturation if it is done too often, for too long or too vigorously. It may also cause bleeding
from the nose. For these reasons, routine suctioning of a nasopharyngeal tube is NOT
recommended.
Positioning
Positioning is an important but often forgotten part of patient care. Prone positioning may
benefit respiratory drive and improve oxygenation (2, 9). However it should only be used
where patient observation is guaranteed and where it is not otherwise contraindicated
(e.g. abdominal distension). Regular changing of position with patient cares will also avoid
pressure sores which can result in secondary infection and in pain.
Tubes should only be suctioned if there are signs of deterioration or signs of
excess secretions (rattly sounds, visible secretions).
Nasal prongs do not need to be suctioned. If blocked prongs are suspected or if there are
audible / visible secretions or signs of deterioration, gently remove the prongs from the nose
and wipe them clean. While the prongs are out, gently suction each nostril according to
protocol. Replace the prongs and suction the mouth.
Thermoregulation
Thermoregulation is an important part of care of all sick and small babies. Thermoregulation
means paying care to a baby’s temperature and ensuring he / she is neither too cold
(hypothermic) nor too hot (febrile). Sick and small babies are not good at controlling their
own temperature and are easily affected by problems with the environment (e.g. drafts,
warmers set at inappropriately high temperatures). They frequently need to be cared for
under a radiant warmer or, if available, in an incubator to assist with thermoregulation. If
babies become either too hot or too cold their general condition may deteriorate. More
information can be found in Managing Newborn Problems (WHO 2003).
Infection Prevention
Infection prevention is an extremely important part of care of all newborns. Sepsis can cause
serious deterioration or even death.
Important aspects of infection prevention for babies on CPAP include:
– Strict handwashing
– Use of aseptic technique for procedures (including preparing a nasal tube for CPAP and
suctioning)
– Use of aseptic technique for handling IV fluids, drips and medications
– Correct isolation practices
– Correct cleaning and disinfecting of equipment (i.e. the CPAP), p. 99
– Changing the bottles and patient circuits as recommended
– Using only sterile or disinfected water to fill the bottles
– Strict attention to preventing injury to the nose
– Maintaining breastfeeding
Again, for more information refer to Managing Newborn Problems (WHO 2003).
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CPAP and the Baby with Difficult Breathing
Figure 13. Prone nursing on CPAP
Providing close attention to all the elements of supportive care will help to minimise
complications due to CPAP and complications due to other medical problems that
commonly affect preterms (e.g. PDA, NEC and sepsis).
The correct technique for suction
Suction equipment should always be available at the bedside of a baby on CPAP.
Equipment: functioning suction, sterile suction catheter of correct size and clean non-sterile
gloves.
ETT Size (mm)
Suction Catheter Size
2.5
5 FG
3.0 - 3.5
6 - 7 FG
4.0 - 4.5
8 FG
The suction catheter should be pre-measured against the nasal CPAP tube / adaptor. The
length that the suction catheter should be passed is the same length as the cut tube plus
adaptor. Mark this distance somewhere to serve as a reference (e.g. on the observations
sheet).
Procedure (use 2 nurses if possible)
– Note baseline vital signs (HR, RR, SpO2)
– 1 nurse washes hands and puts on gloves, picks up sterile catheter and attaches to
suction tubing without allowing the catheter to touch anything else
– 2nd nurse holds and disconnects the ETT adaptor from the CPAP tubing and holds the
81
–
–
–
–
–
–
–
–
–
–
baby’s head and the CPAP tube during the suction
Nurse 1 passes the suction catheter into the tube to the predetermined distance (do not
pass it further – it will irritate the mucosa)
Apply suction (80-100cmH2O) while withdrawing the catheter using a circular motion.
Suction < 6 seconds in total
Note vital signs
Only repeat the procedure if there were a lot of secretions
2nd nurse reconnects the baby
Suction the other nostril and the mouth (you may change to an 8F catheter)
Suction a little sterile water into the tube to clean the tubing, removes the catheter and
discards
Turn off suction, remove gloves and wash hands
Document suction, result of suction (amount and consistency and colour of secretions)
and response of baby to suction (did vital signs improve?)
If the baby requires suction and a 2nd nurse is unavailable, the 1st nurse detaches the tube
from the CPAP with one hand, steadies the tube using the same hand and inserts the
catheter using the other “clean” hand. Care is especially required to steady the ETT and
infant’s head to ensure the tube doesn’t accidentally come out.
9.7
What if the baby is deteriorating?
Clinical signs
The signs that a baby is deteriorating are the same as the signs that the CPAP is not
working (p. 75)
Possible reasons for deterioration
If a baby deteriorates after having been stable or improving on CPAP it may be due to a
machine / circuit problem or it may be a patient problem.
A BABY MAY DETERIORATE WHILE ON CPAP BECAUSE OF
A machine / circuit problem
–
–
–
circuit disconnection
nasal tube blockage
oxygen supply run out or turned off
A baby problem
–
–
–
–
–
–
Recurrent Apnoea
Underlying lung disease is worsening
Complication of CPAP
lung overdistension, pneumothorax
gastric distension, aspiration
Development of a new problem such as
– sepsis / pneumonia
– PDA
A stepwise action protocol for what to do when a baby is deteriorating is found on p. 84.
Following the protocol will enable the health worker to determine a probable reason for the
deterioration as well as to institute steps to fix the problem and improve the baby’s condition.
The first step is to increase the oxygen supply and the second is to check for apnoea. The
oxygen supply, the CPAP circuit and machine are checked next. Finally, the tube is checked.
If no problem is found then the baby has deteriorated either because the underlying lung
disease is worse, because of an acute complication of CPAP (pneumothorax, lung overdistension or aspiration) or due to the development of another medical problem. The health
worker should always call for help if a reversible problem is not found quickly.
Table 12 lists the clinical signs to diagnose each of these possibilities as well as the
appropriate actions to manage them. A portable CXR is very useful to help to differentiate
between the possibilities. A transilluminator is very useful in quickly confirming a
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CPAP and the Baby with Difficult Breathing
83
pneumothorax.
Each of the individual causes of acute deterioration 23 is also discussed in more detail on the
following page. Note, other medical problems such as PDA, NEC, IVH which may all cause
general deterioration are not covered here, refer to Managing Newborn Problems (WHO
2003).
Increasing CPAP settings when the baby deteriorates
Oxygen should be increased as the immediate first step when a baby has deteriorated.
The oxygen is increased while the health worker is trying to determine the cause of the
problem. Pressure (PEEP) may also need to be increased, at least temporarily, in managing
a deterioration (see table). However this must be done with caution. If pneumothorax or
lung overdistension is suspected, pressure should not be increased. In these situations
the doctor should try to see whether decreasing the PEEP improves the baby’s condition.
Ideally a CXR will have been obtained first.
Maximum settings
Oygen may potentially be increased up to 100% (i.e. 6L oxygen, 0L air) however if a baby is
requiring > 70% oxygen then the baby has very severe hypoxia. This signals that the CPAP
may not be sufficient to help the baby.
Pressure should not normally be increased beyond 8cms. On occasion, 9cms may be used
on a bigger baby.
If a baby does not respond to high oxygen and maximum pressure then CPAP may not
be enough to treat the underlying lung problem (p. 15). If ventilation is an option then this
should be considered at this point. The decision about whether or not to proceed at this
point will depend upon the availability of local resources to manage an intubated baby and
must be made by the most senior clinician available. As mentioned earlier, if available, blood
gas analysis may also be used to help make this decision.
Protocol - what to do when a baby is deteriorating
1. Increase the FiO2 – by 10-20% or more if needed
2. Quick Check for apnoea
a. If present, stimulate the baby.
b. If the baby does not begin breathing within 20-30 seconds, take off CPAP and
ambubag / mask with oxygen
b. Oxygen on and cylinder full?
c. Settings correct (PEEP, oxygen, flow rate)?
d. Bubbling?
i. Fix any problem immediately
ii. If no improvement, continue
4. Quick clinical assessment
a. Auscultation - pneumothorax
i. If unsure, transilluminate or order portable CXR
b. Hypotension / reduced cardiac output?
i. Try bolus of fluid (10cc/kg normal saline)
5. Check the tube - obstruction
a. Suction the tube and airway
b. Change the tube if you have any concern that it is blocked
c. If this does not resolve the problem, continue
6. Increase the settings
a. Oxygen 5% increments
b. Pressure increments 1cm, up to a maximum of 8; do not increase if suspect
hyperinflation or pneumothorax
7. Urgent CXR if possible
Call for help if you do not quickly find a reversible problem!
Acute complications of CPAP which may cause deterioration
Tube obstruction
This is a common problem and all health workers working with CPAP must be competent
in detecting and managing tube obstruction. Obstruction may cause sudden and severe
deterioration in the baby’s condition. It can be prevented by close observation for early signs
of obstruction (table 12) and good tube care. When CPAP is used for more than a couple of
days the presence of the tube tends to provoke secretion production. Obstruction becomes
more likely at this time. If a blocked tube is suspected the tube should be suctioned. If this
improves the baby’s condition no further action is needed. If the catheter does not pass
readily or easily the tube may be blocked, remove it and change for a new one.
3. Quick Machine Check
a. Connections intact?
23
It is not possible to include here discussion of the possible ‘new medical problems’ that are not
specifically related to the CPAP. Here we have focused on those specifically related to the CPAP treatment.
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CPAP and the Baby with Difficult Breathing
85
Overdistension of the lungs
Overdistension of the lungs occurs when inappropriately high CPAP pressures are being
used relative to the lung compliance or when lungs are unevenly inflated (e.g. MAS).
Overdistension may result in hypoxia. It may also cause hypotension because overdistended
lungs reduce the amount of blood returning to the heart. The distensibility of the heart is also
reduced (29). A portable CXR can confirm the suspicion of hyperinflation. It is diagnosed
when more than 9 posterior ribs can be seen and the diaphragms appear flattened.
Overdistension may be improved by reducing the CPAP pressure and by giving fluid bolus/
es (aliquots of normal saline 10cc/kg) to optimise blood volume. However overdistension
may be difficult to reverse, particularly if it is localised or uneven such as is often seen in
MAS.
Figure 14. Secretions around end of a cut ETT
As tube obstruction is a common and potentially life-threatening problem,
two spare cut and tied tubes should always be at the bedside (one the
same size, one half a size down) in case the same size tube will not insert
in an emergency.
Sepsis
Either local (skin, lung) or systemic sepsis may occur as a complication of poor infection
prevention practices and / or injury to the nasal skin, which then serves as a portal of entry
for bacteria. For signs of systemic sepsis and management of sepsis refer to Managing
Newborn Problems (WHO 2003). Adhering to strict infection prevention and good care of
the nose will greatly reduce the likelihood of complications of sepsis.
Pneumothorax
Pneumothorax is an important and potentially very serious complication of CPAP (20). It may
result in sudden and severe deterioration of the baby’s condition. Pneumothorax is especially
likely to occur when high pressures are being used. It is also more likely in babies with HMD
during the recovery phase when the baby’s oxygen requirement is decreasing and lung
compliance is improving. Staff caring for babies on CPAP must be competent in recognition
and management of pneumothorax. Hospitals with CPAP should have a transilluminator
available in the neonatal ward and 24 hour facility for portable CXR to enable prompt
diagnosis of pneumothorax. A pneumothorax kit (p. 94) must be readily available in areas
where babies are being treated with CPAP. A pneumothorax protocol is included p. 114.
Gastric distension
Gastric distension on CPAP is commonly referred to as ‘CPAP belly’. It is a common
complication. It refers to distension of the abdomen due to passive entry of gas flow into the
stomach during CPAP. It is worse when higher flows are used. It can usually be prevented or
contained by using an orogastric tube on free drainage while babies are on CPAP (the tube
is closed only for 1/2 hour after a feed). Nursing the baby PRONE may also help prevent
or reduce CPAP belly. Gastric distension can worsen a baby’s respiratory distress by
compressing the lungs and reducing lung volume. Aspiration of stomach contents is more
likely to occur when a baby has CPAP belly and may significantly worsen oxygenation and
respiratory status.
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CPAP and the Baby with Difficult Breathing
87
88
CPAP and the Baby with Difficult Breathing
89
Poor peripheral perfusion
Hypotension
Hypoxia
Signs CPAP is not working
Overdistension
of the lungs
Lung disease is
getting worse
Careful use of PEEP
Treat underlying lung
Increase CPAP settings (FiO2, disease according to
pressure) as needed.
cause.
Ensure baby on Antibiotics.
Reduce PEEP carefully
IV volume bolus
# CPAP sounds (the sounds of the gas flow of the CPAP that are transmitted to the chest) or breath sounds
(Note: unrelated causes such as sepsis, PDA are not covered here; see neonatology textbooks).
CXR
CXR shows hyperinflation
Signs CPAP is not working
Aspiration
As above
Increase CPAP settings (FiO2,
Regular small volume OG
pressure) as needed.
feeds
CXR may help and can
confirm correct position
Abdominal distension
OGT on free drainage
Prone nursing
Minimise flow (5L/minute)
OGT on free drainage
Prone nursing
Minimise flow (5L/minute)
Withold feeds
Observation
(Girth measures are not
reliable)
CPAP belly
Pneumothorax
Careful use of PEEP
Avoid high pressures
Wean pressure promptly
when HMD improving.
Keep the baby calm.
Increase oxygen
Treat promptly
- minimise PEEP (to 5cm)
- insert chest drain / ICC
(p. 117)
Transillumination of affected
side.
Portable CXR
Tube
obstruction
Signs CPAP is not working
Reduced breath sounds
unilaterally.
Suction catheter does not
pass easily through the
length of the tube (p. 27).
Signs CPAP is not working
Reduced sounds in chest#
Reduced chest movement
No bubbling
Apnoea
Good tube care
(suctioning regularly)
Appropriate humidification.
Observe the breathing for
20 seconds.
Desaturation +/- bradycardia
The baby is not breathing
There is no bubble in the
expiratory bottle.
How to prevent
Apnoea protocol (p. 16)
Increase FiO2
Stimulate the baby
Use stimulant medication
If no response and severe
for preterm babies (p. 18).
hypoxia or bradycardia, remove Prone nursing.
CPAP and ambubag / mask
with oxygen.
How to manage
Increase oxygen
Suction the tube - if cannot
pass catheter then remove
tube and replace with new
immediately.
How to confirm diagnosis
Signs
Complication
Table 12. Baby is deteriorating
9.8
Weaning and Stopping CPAP
When to wean CPAP
Weaning means reducing the support that is being provided to the baby from the CPAP.
Weaning can be done when the baby’s respiratory effort is improving (RR reducing, minimal
retractions, no grunt or flare) and SpO2 is normal (preterm babies 88-93%, term babies >
90%).
The general principals of weaning from CPAP are as follows:
– wean only one thing at a time (i.e. pressure or FiO2)
– wean gradually – do not be tempted to wean quickly. Wait at least 6 hours in between
changes of pressure; FiO2 can be weaned more quickly, depending on baby’s condition
– always observe a baby for at least 30 minutes following a change to settings; don’t wean
if you cannot stay around to observe the effect of the changes
– Oxygen:
– FiO2 should be weaned before pressure if FiO2 is > 50% UNLESS the baby’s
problem was pneumothorax or overdistension. In this case, wean pressure first, until
it is 5 or 6 cms, then reduce FiO2.
– Reduce FiO2 in steps of 5%
– Pressure:
– Pressure should be weaned 1cm at a time
– Reduce pressure to 5cm; there is NO benefit in reducing pressure to < 5cms
–
–
Place the baby in the prone position if possible (only if oxygen saturation monitoring is
available and nursing staff to remain with the baby).
Remain with the baby and observe closely for at least an hour after taking the baby
off.
– Watch closely for apnoea, increasing work of breathing, deterioration of vital signs.
– Monitor SpO2 continually if possible.
– Withhold feeds.
Neither a CXR nor ABG is essential to trial off CPAP. Clinical criteria can be used to guide
the trial and to determine whether the baby is able to remain off CPAP or whether the baby
needs to return to CPAP for a further period of treatment before trying again.
If a baby fails a trial off CPAP wait at least another 24 hrs before attempting off again.
If a baby is stable after 4 hours off CPAP it is unlikely the baby will need to go back on.
Feeds can be restarted. Observations should be done hourly for the first 4 hours off CPAP.
After that time, if the baby is well and has minimal respiratory distress then observations can
be reduced to 4 hourly.
When to stop the CPAP
In general terms a baby can be tried off CPAP when
– The baby is stable for at least 48 hours.
– The FiO2 is 35% or less for at least 12 hours
– PEEP is 5cm at least 24hrs (consider stopping when PEEP 6cm in a bigger baby if the
FiO2 is satisfactory).
– There is no apnoea
– The baby is haemodynamically stable and no other medical problem
Protocol for stopping CPAP
–
–
–
–
–
–
–
–
90
Withold feeds for 4 hours prior to trying the baby off.
Prepare a spare cut and tied nasal tube to be used in case the baby fails the trial off.
Ensure suction, oxygen and ambubag/mask are at the bedside and working correctly.
Aspirate the stomach and discard any aspirate
Suction the mouth, the free nostril and the tube
Explain what you will do to the parents – including the possibility that the baby may not
cope with coming off the CPAP and may have to be put back on.
Remove the tube and quickly suction the nose and the mouth again.
Give oxygen by mask (6L/min), nasal prongs (2L/min) or headbox (10L/min).
CPAP and the Baby with Difficult Breathing
91
10.
HOW TO MAKE CPAP WORK WELL IN YOUR HOSPITAL
Hospitals who decide to make CPAP available must understand the issues that determine
its safe and effective implementation. Certain prerequisites must be met; these are
summarised in the table below. The responsibility for effective implementation of CPAP lies
across hospital disciplines.
Discipline
Administration
Responsibilities / Prerequisites
Ensuring the necessary staff (numbers, skills, medical and nursing,
biomedical, radiology) are available to care for CPAP babies.
Ensuring staff are sufficiently skilled through training and ongoing
competency checks.
Ensuring the hospital has written policies and procedures for safe use of
CPAP, outlining how, when and where it will be used.
Ensuring the availability of the necessary equipment and supplies to run
CPAP.
Ensuring access to biomedical support for CPAP.
Hospitals without ventilators should also have policies for when to refer to
other centres for a higher level of care, if available.
Medical staff
24 hour in-house cover
Trained and competent in using CPAP, including recognising and managing
complications
Nursing staff
24 hour in-house cover
Minimum nurse:patient ratio of 1:32
Trained and competent in using CPAP, including recognising when to call
medical staff
Oxygen
Guaranteed reliable supply
Maintenance of oxygen supply system is readily available
Biomedical
maintenance
If present in-house, then have skills for basic maintenance and troubleshooting of the CPAP. Know when and how to call for external assistance.
Radiology
CXR, preferably portable, available 24 hours.
In current times, pressures are on hospitals to acquire the latest technologies. However,
prior to deciding to offer CPAP, hospital administration and clinicians should review their
demand for CPAP. Neonatal ward data should be reviewed to determine how many cases
of RDS are likely to present each month. It has been suggested that, as for many practical
skills, it is difficult to maintain competency in CPAP if a hospital is treating fewer than one
case per month (20). Even at these levels skills may need to be maintained by regular
rotations to higher level hospitals. For hospitals with very low caseloads it is better to focus
on improving a referral system to the next level health facility where CPAP is offered.
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CPAP and the Baby with Difficult Breathing
CPAP will only be effective in reducing neonatal mortality from RDS when
the prerequisites for its safe implementation are fulfilled. This is a joint
responsibility of hospital administrators, clinicians and biomedical as well
as those responsible for oxygen supplies.
Conclusion
CPAP cannot save every baby with respiratory distress however, provided it is used
correctly, it will cure to a large number of babies who would otherwise die or require
ventilation. Use of CPAP in the developed world has improved the outcomes of neonatal
respiratory distress. It has the potential to do the same in low resource contexts providing
that due attention is given to the issues that have been highlighted here.
For hospitals that are considering procuring ventilators for neonatal care, first mastering
CPAP is excellent preparation before moving to more complex technologies and all of their
associated requirements.
10.1 Minimal equipment list for CPAP
Basic resuscitation supplies for neonates
–
–
–
–
–
Ambubags (250-750mls reservoir)
Face masks (neonatal sizes 0, 1)
Oxygen tubing
Suction catheters (sizes 6, 8, 10, 12F)
Suction (wall or portable electronic, manual foot operated)
Oxygen supplies
–
–
–
–
–
–
–
Oxygen source (wall oxygen, cylinders, concentrators)
Medical oxygen regulators
Face masks (neonatal size)
Oxygen hoods
Nasal prongs (1mm, 2mm internal diameters)
Saturation monitor with neonatal probes
Oxygen analyser (optional)
CPAP
–
–
–
–
–
–
CPAP machine (2)
EMW CPAP wash bath
Interfaces (ETT, prongs)
Cleaning solution (Bayclin, Presept, other equivalent)
Strings, tapes for securing tubes
Caps, tapes if using prongs
93
Support equipment
–
–
–
–
–
–
–
–
–
Transilluminator
Portable CXR
Infection prevention supplies
Heating devices (radiant warmer)
Stethoscopes
Pneumothorax kit (butterfly needle, syringe, 3-way tap, sterile dressing pack)
Intercostal catheters
Underwater drains
Feeding tubes (sizes 6, 8, 10, 12F)
10.2 Job aides - bedside protocols
These protocols are meant to be able to be hung and used at the bedside. List of protocols
included here.
The machine
Using and Caring for CPAP
1. checking the machine before use
2. turning on and adjusting the controls for operation
3. care in use
4. turning off the CPAP machine
5. cleaning
6. assembling / reassembling
The patient
Nursing protocols
1. Starting the baby on CPAP
2. Caring for the baby on CPAP
3. Stopping CPAP
4. Preparing the patient interface (tube or prongs)
Medical protocols
1. How to manage a deterioration on CPAP
2. Pneumothorax – detect, manage
Counseling for parents
94
CPAP and the Baby with Difficult Breathing
95
11.
USING AND CARING FOR THE EMW CPAP UNIT
CPAP is Continuous Positive Airway Pressure
compressor stand so that the compressor is secure.
5. Check all the other components are correctly connected (see cleaning aide).
a. Check the gas hoses are correctly connected
b. Check the bottles are correctly set up
c. Check the patient circuit is correctly set up
6. Fill the thermos bottles with distilled or sterile water to the top red line on each bottle.
Screw the blue lid on each bottle firmly.
11.2 Turning on and adjusting the controls for operation
1. Turn the unit on at the wall and turn on the ‘ON’ switch on the CPAP.
a. The lights on the front panel should all come on and the alarm will sound briefly.
b. The base of the posterior thermos bottle and the inspiratory arm of the patient circuit
should begin to heat. It will take about 5 minutes to be able to feel this temperature
increase.
c. The air should begin to bubble through the inspiratory bottle and the compressor
should be making a noise. If this does not happen, check the air compressor is
plugged in and / or try changing the air compressor with another.
d. If none of these things happen, unplug the unit and check the wall power outlet is
working by plugging in another electric device. In any other case, contact Biomedical
Engineering.
2. Dial up the desired oxygen concentration (FiO2) by adjusting the flow meters for air
and oxygen according to the label on the blender. Unless the doctor instructs otherwise,
begin with a combined flow (air + oxygen) of 6L/min. The flow may need to be adjusted
after the baby is connected and the baby’s condition and the amount of bubbling is
observed.
3. Set the temperature of the inspired gas. The possible range is between 35 oC and
39oC. First check the electronic display goes down to 35OC and up to 39OC when the
knob is moved to the extreme left and the extreme right. The usual starting temperature
is 36o - 37.5oC. The temperature may need to be higher for small or sick babies; the
doctor may modify this.
11.1
Checking the machine before use
1. Remove the cloth cover and check the machine is clean. If it is not clean, wipe it over
with a damp cloth soaked in alcohol.
2. Check the mains cable and plug – make sure there are no breaks in the cable and that
the plug is not showing any exposed wires (brown, blue, green, black or white).
3. Lock the wheels with the brake.
4. Make sure the 4 rubber ‘feet’ of the air compressor are sitting in place on the air
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CPAP and the Baby with Difficult Breathing
4. Set the humidity of the inspired gas; it is usual to begin at ~50% but this will need
to be adjusted in use depending on the ‘rain’ (amount of water droplets that form) in
the inspiratory arm. Humidity requirements will also vary according to the ambient
temperature and humidity. If the ambient temperature is cold and dry (AC in use), more
humidity may be required.
5. Set the level of PEEP by adjusting the height of the metal leg in the expiratory thermos
bottle, measured against the cm readings on the side of the bottle. The usual starting
PEEP is 5cm H2O. This may need adjusting depending on the baby’s condition and
response to CPAP.
97
6. Occlude the patient connector on the end of the patient circuit with your thumb and
check that bubbling begins in the expiratory bottle. If no bubbling begins, check the gas
flow is on and check for leaks in the circuit.
11.3 Care in use
1. When patient observations are performed, also check
a. The machine settings are as ordered. Sometimes settings are inadvertently moved.
b. The circuit is secure – bottle lids and all connections are tight.
c. The oxygen cylinder is not approaching empty or, if connected to a wall oxygen
outlet, that the pressure gauge on the wall supply outside shows that the external
cylinders are not approaching empty. If the pressure gauge shows nearly empty,
change over the cylinders and report the empty cylinder to the Oxygen Technician.
d. The water in the expiratory bottle is bubbling. If there is no bubbling,
disconnect the baby from the circuit and occlude the end of the circuit. If bubbling
recommences, there is a problem with the baby (apnoea or a leak from the mouth).
If there is still no bubbling, there is a machine problem. Check the gas flow is on,
check all circuit connections looking for a leak. If you cannot resolve the problem
quickly, change the machine.
e. The water level in the inspiratory bottle is up to the red line. Because heated water
evaporates very quickly, check the level every couple of hours and top up (distilled or
sterile water) as needed.
f. The circuit tubing for ‘rain out’ (excess water collecting in the base of the tube) and
empty it back into the bottle by lifting the tubing and shaking GENTLY. Be careful not
to dislodge the tube from the baby’s nose while you do this.
g. The measured temperature of the inspired gas (shown on the lower screen)
is the same as the set temperature. If there is a difference of more than 1 degree,
check there is enough water in the inspiratory bottle. If there is enough water and the
problem remains, call Biomedical Engineering.
11.4 Alarms
The alarm on the CPAP unit has both a LIGHT and a SOUND. For the
sound to work the orange button must be pushed IN. The sound can be
turned off by pushing the orange button OUT. When there is an alarm
condition the alarm light will always be on.
The RED alarm light will illuminate and the orange buzzer will sound if
a. The temperature in the patient circuit is too low. The bottom screen will display a
warning message. Note that the patient circuit can take a little while to reach the
set temperature. During this time the temperature-too-low alarm may start. This is
normal, and no action is required. However, in other circumstances: Check the gas
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CPAP and the Baby with Difficult Breathing
flow is turned on. Check for leaks in the circuit – are the air compressor and the
oxygen supply and the common gas tubing all connected correctly? Are any of the
tubes disconnected or bent? Check if air conditioning or vents are blowing across
the patient circuit. If no correctable problem is found, change machines and call
Biomedical Engineering.
b. The temperature in the patient circuit is too high. The bottom screen will display a
warning message. Some reasons for temperature too high could be:
i. Temporary overshoot. This is to be expected sometimes as a normal part
of controlling the temperature. This overshoot should not last longer than 3
minutes.
ii. Sudden change in ambient conditions. For example, presence of an air
conditioner or vent.
iii. Blockage somewhere in the patient circuit.
iv. Machine failure.
c. Depending on the reason for temperature being too high you may need to take the
following actions: disconnect the patient (provide CPAP with bag/mask if needed
or swap to another machine/circuit). Turn off the CPAP for ~10 minutes and check
that the sensor cools down (hold under a fan if available). Provided the sensor cools,
turn the machine back on and try to use it again. Observe carefully. If the problem
recurs, change the baby to another machine and report the problem to biomedical
engineering.
11.5 Turning off the machine
When the baby is ready to be trialed off CPAP (see patient indications), disconnect the
baby from the patient circuit and turn off the machine on the front of the control panel. The
oxygen flow will need to be turned off as well.
11.6 Care of the CPAP unit between uses
1. The CPAP unit and circuit must be washed after use and before storing.
2. After the machine is washed and cleaned, reassemble the machine fully, cover with a
clean cloth and store.
3. The inlet and outlet air filters on the air compressor will need to be intermittently checked
and cleaned or replaced by BME as needed.
Cleaning the CPAP unit
1. Ensure the CPAP is turned off and the power cord is disconnected from the wall.
2. Take the heating wire out of the patient circuit and check it for breaks or kinks. It is not
necessary to disconnect the wire from the back of the unit to do this. However, 2 people
are required. One person holds the circuit out straight while the other takes out the wire.
If there are breaks or kinks in the wire it cannot be used - call Biomedical Engineering.
99
7. Place the bottles and circuits in the washer bath. The bottles stand in the brackets.
Plug the small clear tubing from the bath into the common gas inlet on the inspiratory
bottle. Plug the open ports in the bottle lids with the plugs supplied. These plugs seal
the 2 bottles and tubing together so that the water / sterilizing agent will reach all inner
surfaces. (Note: 2 sets of brackets allow 2 bottle sets to be washed at one time).
3. Wipe the heating wire with alcohol then leave it hooked over the machine whilst the
patient circuit and bottles are disinfected.
4. Disconnect the common gas tube from the lid of the inspiratory bottle and then lift both
bottles and the patient circuit off the machine.
5. Wash the bottles and the circuit with dishwashing detergent and cold water. Then rinse
off the detergent.
6. There are 2 versions of the MTTS washer bath:
a. Stainless steel bucket: Fill with 20L of disinfectant solution - Bayclin 0.5% solution mix 18L water with 2L 5% Bayclin (sodium hypochlorite).
b. Plastic bucket: Fill with 13L of disinfectant solution - Bayclin 0.5% solution - mix
11.7L water with 1.3L 5% Bayclin (sodium hypochlorite).
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CPAP and the Baby with Difficult Breathing
8. Turn ON the switch on the bath and allow the wash to run for 2 hours.
9. Remove the bottles / circuits and rinse in sterile (bottled) water.
10. Allow the bottles and tubing to drip dry or dry using the air compressor or other similar
device (in a very humid environment it will take a long while to completely dry the
tubing without using a drying device).
11. When the components are dry, reassemble the machine.
NOTE: After prolonged use you may see white calcium appearing inside the bottle and tube.
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To get rid of it you should use 3 liters of vinegar and 3 liters of hot water mixed together.
Soak the bottle set and silicone tube inside the basin. There is no need to run the water
pump in this case. Leave the bottle set and silicone tube to soak overnight. Next day the
calcium will have disappeared.
Assembling / reassembling the CPAP unit
1. Plug the cable from the air compressor into the 220V power socket on the back of the
CPAP unit.
2. Plug and screw the heater wire into the back of the CPAP unit (never disconnect
the heater wire from the back of the unit unless it is broken / kinked. Forcefully
disconnecting the wire may damage the wire).
3. Connect the clear air hose to the air outlet on the back of the oxygen blender.
4. Connect the blue oxygen hose to the wall oxygen outlet or oxygen cylinder regulator.
5. Place the bottles in the bracket on the side of the unit
a. The inspiratory bottle is the humidifying bottle. It sits in the posterior bracket.
b. The expiratory bottle is the pressure bottle, the bottle which provides the ‘PEEP’. It
has the numbers 1-10 in cms printed on the side in addition to the 400cc markings,
which both bottles have. This bottle sits in the anterior bracket.
6. Connect a disinfected patient circuit to the unit. Insert the clean heating wire in the
inspiratory limb. Attach the ends of the patient circuit to the thermos bottle lids. The
white connector end of the inspiratory arm of the circuit attaches to the lid of the
humidifier thermos bottle. The black connector end of the expiratory arm of the circuit
plugs into the lid of the pressure thermos bottle. Rest the ‘neck’ of the circuit on the
metal support clips on the arm of the CPAP unit.
7. Connect the small clear tubing from the back of oxygen blender, the common gas flow,
to the small knob on the top of the inspiratory humidifier thermos bottle lid.
8. Cover the whole unit with a cloth. It is ready for use.
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CPAP and the Baby with Difficult Breathing
12.
NURSING PROTOCOLS
12.1 Starting the baby on CPAP
1. Counsel the parents (see separate sheet).
2. Attach continuous oxygen saturation monitoring if available.
3. Record baseline observations on patient monitoring form
a. Vital signs:- PR, RR, temperature, oxygen saturation
b. Respiratory effort (retractions, grunting, flaring)
c. Peripheral perfusion (BP, warmth, colour)
d. Abdominal distension
e. General condition – agitation / restlessness; alertness
4. Check resuscitation equipment (bag / mask and suction) is available and ready for use
next to the baby’s bed. Ensure adequate oxygen supplies for both the ambu-bag and
CPAP machine.
5. Prepare the nasal catheter (See separate protocol) as well as a 2 SPARE catheters,
tapes and ties to have ready at the bedside in case of obstruction.
6. Elevate the head of the bed 30o. If the bed doesn’t move, place a pillow or equivalent
under the mattress to achieve a similar effect.
7. Gently suction the baby’s mouth then each nostril with an 8F catheter.
8. Insert the patient interface into the baby’s nose (See separate protocol).
9. Connect the CPAP circuit to the patient interface (Note: the CPAP unit must be
turned on; all components checked and the settings set before you attach to the
baby)!
10. Observe the water in the expiratory bottle – it should bubble as the baby breathes out.
If there is very little or no bubbling disconnect the circuit from the baby and occlude
the circuit.
a. If bubbling returns there is a baby problem (apnoea or a leak).
i. Check for APNOEA. If apnoeic, stimulate. If no response, remove the tube,
bag / mask with oxygen and call the doctor.
ii. There may be a leak if the baby’s mouth is open. Try closing the baby’s mouth
(lift the chin) to see if this resolves the problem. If it does, this confirms a leak
is the problem.
1) Place a small roll under the baby’s shoulders to extend the neck a
little.
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ii. If SpO2 < 90%, increase FiO2 by 5% and observe response; if saturations
remain < 90%, call doctor. PEEP and / or flow may need to be increased. A
CXR may be needed.
b. Routine observations should include:
2) Use a dummy or a gauze chin strap to stop the leak.
3) Increasing the gas flow (eg 6L to 8L) may improve the bubbling and
compensate for a leak out the mouth however call a doctor before
doing this.
b. If there is still no bubbling when you occlude the circuit, there is a machine problem
i. Check again the gas flow is turned ON.
ii. Check for a circuit leak – check nothing is disconnected and that the bottle
lids are closed firmly.
11. Secure the circuit with tape onto the side of the baby’s bed so that it doesn’t pull the
nasal tube out.
a. Be sure that the circuit arms are lower than the baby so that water droplets that
precipitate in the tube don’t run down into the baby but run back down into the
humidifier bottle.
b. Ensure the CPAP tubing is not pulling up against the baby’s nostrils, but following a
downward position. An upward pulling position will cause pressure areas and nasal
damage.
12. Insert OGT (size 8F or larger) and aspirate then leave it open (this is to prevent ‘CPAP
belly’).
13. Wrap / nest the baby securely so that his arms cannot pull out the tube and so that he is
comfortable.
14. Perform another set of observations at 15 minutes after starting. See care of the baby
on CPAP.
12.2 Care of the baby on CPAP
1. Monitoring
a. Immediate response to CPAP: 15 mins after starting CPAP do another set of
observations.
i.
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If SpO2 > 95%, reduce FiO2 by 5%; continue to reduce FiO2 by 5% every
15 minutes until SpO2 in correct range (85-93% for preterms; 90-95/98%
for term babies).
CPAP and the Baby with Difficult Breathing
Patient observations
Machine observations
1. Vital signs - SpO2, RR, HR
1. Machine settings – pressure, FiO2, flow are they as ordered?
2. Respiratory effort - retractions,
grunting, flaring
3. Peripheral perfusion - colour, warmth,
urine output
2. Circuit connections – are they correct
and intact?
3. Oxygen level – is the cylinder
approaching empty?
4. General level of comfort
5. Tube tapes are secure / prongs are in
place
6. Secretions need suctioning?
7. Nasal skin for redness
4. Water - Does it need filling?; Is it
bubbling?
5. Humidity – is there water (‘rain’) in the
tubing to empty?
6. Temperature reading – is the reading
close to the set temp?
8. Abdominal distension
7. Alarms – is the alarm light on?
Record observations hourly for the first 3-4 hours or until the baby is stable.
Subsequently record observations 2-4 hourly, depending on doctor’s instructions. Any
baby with severe respiratory distress needs ongoing close monitoring (hourly vital signs).
2. If the baby deteriorates
a. Call for help
b. Increase FiO2 10-20% to try and get SpO2 in required range
c. Quick check oxygen supply, connections, machine settings
d. Check for apnoea and treat if present
e. Quick patient assessment for pneumothorax
f. Check if the tube is blocked (p. 81 suction protocol)
g. Doctor will decide whether to increase pressure, transilluminate, order a CXR or
other management.
3. APNOEA episodes: record any apnoea episodes on the patient monitoring form. When
the baby has an apnoea
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a. Stimulate the baby
b. If no response, remove tube and bag / mask with oxygen.
c. CALL the doctor
4. Feeding:
a. Feed the baby via an OGT.
i. Begin feeding as soon as the baby is stable.
ii. After a feed, close the tube for 30 minutes only, then reopen.
iii. Suspend the open end of the OGT by taping it to a pole on the baby’s cot.
This allows the milk to be slowly absorbed and excess gas can still escape.
iv. Before each feed, check the position of the OGT is correct (if you think it has
moved or could be out, replace) and aspirate. If there is > 25% of the last
feed returned, or if the aspirate contains blood or bile, hold a feed and call
the doctor.
b. The mother should be assisted and regularly encouraged to express her breast milk.
5. Care of the nose and suction
a. When doing patient observations, check for pressure areas on the nostril and check
position of prongs / tube. If there is any redness, remove the tapes and ensure there
is no tension on the tube. Gently but securely retape. Change the tube to the other
nostril if the redness persists after you remove the tapes. If using prongs, check
the size and position are correct before reinserting. Apply antibiotic ointment to the
affected area tid.
b. Suction the nose if audible or visible secretions are present or if the baby shows
signs of deterioration. Suction the mouth at the same time. Record the suction on
the monitoring form.
c. Report any bleeding from the nose to the doctor.
7. Positioning: Change the baby’s position every 4-8 hours (front, back, each side). Move
unstable babies less frequently. Be sure to move the baby’s head to the other side each
time.
a. Prone position (lying on the baby’s front) is best for digesting feeds unless there are
specific concerns about the baby’s abdomen. It may also improve respiratory effort
and help reduce apnoeas. Care must be taken to ensure the baby’s face is turned to
the side.
b. 2 people may be needed for position changes in order to prevent tube
disconnections or the tube falling out.
8. Comfort
a. If a baby appears agitated, first check that he does not have signs of deterioration (p.
83) or fever. Call a doctor if signs of deterioration or fever.
b. If it is just that he is unsettled by the tube or the treatment, try swaddling, nesting
and repositioning. Offering a dummy to suck. Ensure a feed has been given
according to schedule. Paracetamol may also be given (15mg/kg/dose 6 hourly) by
OGT. Kangaroo Care may also help settle the baby.
9. Babies on CPAP may be nursed in Kangaroo Care by their parents as soon as they are
stable enough (FiO2 < 40%, few apnoea or bradycardia, only mild retractions). A nurse
needs to be present to help move the baby and needs to frequently monitor the baby
and help the parent.
6. Care of the nasal ETT / prongs and suction
a. There is no need for routine suctioning (too much or too vigorous suctioning may
cause bradycardia and desaturation and may provoke secretion production).
Suction only if
i. There are obvious secretions
ii. There are signs of possible obstruction (desaturation, increased work of
breathing, less bubbling, apnoea). When a suction is done, record it on the
patient monitoring form.
b. Retape the nasal tube (remove old tapes and replace with new ones), or change the
tube, if tapes become loose due to secretions or poor taping technique. Always be
careful to remove the tapes gently when doing this (soak the tape first with a wet
cotton swab) to avoid hurting the baby and causing skin trauma.
c. Change the nasal tube for a new one when there are signs of possible obstruction.
Change the tube regularly if there are a lot of secretions, especially in term babies.
Always change to the other nostril when you insert a new tube unless there is
already injury to that nostril.
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CPAP and the Baby with Difficult Breathing
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12.3 Stopping CPAP
1. Indications to stop CPAP: Baby stable on 5cm PEEP with normal respiratory rate
and minimal or no retractions, maintains oxygen saturations of > 90% in room air, and
minimal or no apnoea or bradycardia.
2. Procedure:
a. Wait until it has been 4 hours since the last OG feed.
b. Ensure the spare cut and tied tube is ready at the bedside if the baby fails.
c. Ensure suction, oxygen and ambubag / mask are at the bedside and working
correctly.
d. Aspirate the stomach and discard any return.
e. Suction mouth and nose well prior to and following removal of the nasal tube.
f. Administer oxygen by nasal prongs or mask.
g. Continue close monitoring of infant’s respiratory status with assessment of vital
signs, work of breathing, and oxygen saturations.
h. Do not remove the CPAP circuit from beside the baby’s bed until the baby has been
stable for at least 4 hours.
i. Hold feeds until the baby has been stable for at least 2 hours off CPAP.
12.4 The patient interface – preparation, insertion and fixation of a cut
ETT
Preparing the tube for insertion
1. Select the correctly sized ETT – the right size is the largest diameter that will
comfortably fit into the baby’s nostril without significant resistance. Suggested sizes are:
Baby Weight
Tube Size
< 1250 grams
2.5 ETT
1250 - 2000 grams
3.0 ETT
> 2000 grams
3.5 ETT
2. Wash hands and put on a pair of gloves.
3. Prepare on a clean cloth or tissue:
a. ETT (take it out of the wrap)
b. String (cut a piece)
c. Tape
d. Scissors
e. Lubricant (if available)
4. Cut the tapes which will be used to fix the tube.
5. Remove the connector from the end of the tube.
6. Measure the distance to cut the tube. To do this, place the ETT against the side of the
baby’s face and measure the distance from the baby’s external nostril and the ear lobe.
Add 3cms which is the distance of tube that should protude from the nose.
7. Using sterile scissors, cut the ETT to the measured length with an oblique cut to the
tube.
8. Reattach the connecting end of the ETT to the cut ETT.
9. Preserve the other part of the ETT by placing it back in the sterile wrapper. It can be
used later when the tube is changed (a single ETT can make 2-3 cut tubes).
10. Tie a piece of string firmly around the tube with a double knot. The tie should be on the
tube at the level where it exits the nostril. This is used to later help to know how far the
tube sits in the nose. It also helps secure the tapes.
11. Lubricate the end of the cut ETT with the baby’s saliva or glycerine / ‘KY’ gel.
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CPAP and the Baby with Difficult Breathing
109
2 people are needed to insert and secure the tube
Inserting the tube
12. Gently but firmly restrain the baby’s arms.
13. Hold the baby’s head straight.
14. You may choose to hold an oxygen mask over the baby’s mouth while you are inserting
and securing the tube.
1
2
3
4
5
6
15. Gently but firmly insert the tube through one nostril, pointing the tube ‘vertically
downwards’ rather than up the nose, leaving 3cms of tube outside the nose.
– If there is bleeding or resistance to insertion try the opposite nostril. Don’t force a
tube as this will only provoke bleeding.
– If trying the other nostril does not succeed, try the next smallest ETT size.
– If the smallest tube does not seem to fit, you can first insert a nasogastric tube (with
the end cut off), size 6, then passing the ETT over the top of the NGT.
Securing the tube
16. Tie a piece of string firmly around the tube with a double knot. The tie should be on the
tube at the level where it exits the nostril to indicate depth of insertion.
17. If a skin protectant is available then place this on the baby’s cheeks before securing the
tube with plaster.
18. One person should hold each end of the string firmly across each cheek while the other
applies the tapes.
19. Secure the tube with tapes as shown in the diagram. When attaching the tapes be
careful NOT to tape so the tube is pressing against the side of the nostril as this may
provoke skin damage.
20. The tube is ready to connect.
12.5 Diagrams of 2 methods of taping tube insert
Single tape: T piece across nasal bridge and both legs wrap around the tube.
Two trouser leg tapes: Top of trousers one cheek and split legs: one above and one below,
one around tube and the other straight across to other side. Mirror image. +/- 3rd whole tape
with hole across all. Much more difficult to change or remove.
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CPAP and the Baby with Difficult Breathing
7
111
12.6 The patient interface – example fixation of nasal prongs
12.7 Counselling sheet for parents of babies on CPAP
Preparing the prongs for insertion
This sheet can be given to parents to read or can be read with them. It is important to spend
the few minutes it takes to help parents understand CPAP because many parents will find
the machinery and attachments frightening. It is very important they understand what they
can and shouldn’t do while their baby is on CPAP. Explaining these things to them helps
them feel more involved in their baby’s care.
1. Select the correctly sized prongs – the right size is the largest diameter that will
comfortably fit into the baby’s nostril without significant resistance.
2. Suction the nostrils as per protocol.
3. Gently insert into the baby’s nose, being sure to angle the prongs ‘down and back’.
Ensure the prongs are not ‘tight’ in the baby’s nostrils.
4. Use fixations that come with the prongs or, makeshift as in the diagram.
1. Why your baby needs CPAP
Your baby is going to be treated with a machine we call CPAP. This machine helps your baby
with its breathing. The baby is getting oxygen as well as other support through the machine
and the tubes that attach to the baby’s nose. The doctors have decided to use the CPAP for
your baby because his / her breathing is very difficult and, if we dont use the CPAP, he will
get sicker. The CPAP helps your baby breathe and helps him get better more quickly.
2. How long will my baby be on CPAP?
Some babies need CPAP for only one day – others need it for several days. How long your
baby is on CPAP will depend upon how sick your baby is. Every day the doctors will check
to see whether your baby can have less CPAP than the day before and whether he is ready
to stop the CPAP or not.
3. What are the possible problems for the baby on CPAP
Most babies have no problems on the CPAP machine. Some babies get some swelling of
the abdomen due to gas from the machine entering the stomach. The nurses can manage
this. Very rarely a baby will have a problem in the lung due to the CPAP machine. This is
called a pneumothorax. IF this happens a doctor will discuss it with you and will also explain
the treatment which is the placement of a small drain tube into the baby’s chest.
4. Feeding, holding, touching and caring for your baby
When your baby is on CPAP he cannot suck from the breast. However he will be given milk
through a tube which passes directly into his stomach. It is very important that the mother is
taught how to express her breastmilk by hand or with a pump so that the milk can be given
to the baby through the tube. Breastmilk is the best milk for the baby’s health even when the
baby is on CPAP.
You can touch your baby while he is on CPAP. It is very important that your baby knows you
are close – you can speak or sing to him, hold his hand, caress him. When he is well enough
the doctors and nurses will help you nurse him in Kangaroo Care (see below).
Your baby will still need you to change his wet or dirty clothes / wraps. The nurses will show
you how you can do this gently, by lifting the baby’s bottom or legs. As long as you don’t
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CPAP and the Baby with Difficult Breathing
113
move your baby’s head or chest, changing the cloths will not disturb the CPAP.
–
5. Does CPAP hurt my baby?
CPAP does not hurt your baby or cause your baby pain. Some bigger babies find it
frustrating having the tube in their nose and may appear unsettled. If you think your baby
is uncomfortable then let the nurse or doctor know. There are various ways they may help
your baby settle such as wrapping him snuggly, giving him a dummy to suck or a small dose
of medicine. If your baby is well enough, they may organise for him to rest on your chest in
a position we call ‘Kangaroo Care’. This will help him settle and is also good for your milk
supply. The nurses can explain this more.
6. Is there anything I shouldn’t do?
It is important that you do not touch the CPAP machine. Be careful when you are near the
bed not to bang into the machine. In no circumstances should you touch any of the machine
controls.
If you have any worries about your baby at any time, please call a nurse or
doctor to help you.
12.8 Pneumothorax protocol24
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a lantern and is clearly different from the other side.
If you suspect a pneumothorax on transillumination AND the baby is managing to keep
SpO2 > 85% on the increased oxygen, try and get a portable CXR to confirm the size
and position of the pneumothorax (a lateral decubitus CXR will confirm the air as anterior
or posterior).
If you suspect a pneumothorax on transillumination AND the baby is NOT managing to
keep SpO2 > 85% on the increased oxygen or the pneumothorax is causing tension
(severe respiratory distress, displaced apex, reduced blood pressure), drain the
pneumothorax using a butterfly needle (see below). Get a portable CXR as soon as
possible.
Definitive management
Once CXR confirms pneumothorax:
– If pneumothorax is > 20% of the lung volume, or the baby is on positive pressure
ventilation, or if the baby is on CPAP and the baby has moderate respiratory distress or
oxygen requirement or the pneumothorax has caused a deterioration, then it will need to
be drained with an intercostal catheter (ICC). Insert according to protocol.
– If pneumothorax is < 20% of lung volume AND the baby is stable then try to manage
conservatively and follow progress with a repeat CXR. Reduce the CPAP pressure
slowly towards 5cm and maintain FiO2 as high as needed to keep SpO2 in required
range. In term babies 100% oxygen may facilitate resolution of the pneumothorax; in
preterm babies do not use more oxygen than is required to keep the saturations in the
normal range. Take off CPAP as soon as baby meets criteria to do so.
Signs that suggest a possible pneumothorax
The baby deteriorates AND
– uneven breath sounds in the chest (one side decreased relative to other)
– may be hyperinflation of one side
– apex beat of the heart may be displaced
– subcutaneous emphysema / crepitus of air under the chest skin (RARE)
– The deterioration may be sudden and severe, or more gradual. Smaller pneumothoraces
may be aymptomatic. Large pneumothoraces may be ‘under tension’ with secondary
reduction in cardiac output (blood pressure); it is a medical emergency.
Management of pneumothorax
Increase oxygen to try and obtain saturations in the desired normal range. Give IV fluid bolus
(10cc/kg of normal saline) if the baby’s perfusion is poor.
Confirm diagnosis
– If you have a transilluminator, turn off all lights and place the light against each side of
the chest in turn. If a significant pneumothorax is present, the affected side will glow like
24
Procedural protocol adapted from protocols at Department of Neonatology
Children’s Hospital & Research Center Oakland, California USA (provided by Dr Priscilla Joe) and Royal
Children’s Hospital Melbourne, Australia, medical guideline; Chest tube insertion @ www.rch.org.au
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CPAP and the Baby with Difficult Breathing
Figure 15. CXR showing large right sided pneumonthorax in an intubated baby
http://img.medscape.com/pi/emed/ckb/pediatrics_cardiac/973235-976801-815.jpg
Draining a pneumothorax with butterfly needle
Needle aspiration is best reserved only for emergencies when the baby’s clinical condition
does not allow you to wait for a portable CXR and placement of a proper ICC. If the doctor
is very experienced and can quickly and competently place an ICC, even without a CXR,
115
this is the preferred option. It is also acceptable to use this technique if the operator doesn’t
have the skills and / or resources to place an ICC however the procedure carries a risk of
CAUSING a pneumothorax.
Equipment
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Butterfly needle 23-25G
10-20cc syringe
3 way stop-cock
sterile gloves
sterile dressing pack
cotton wool swabs
antiseptic solution (70% alcohol can be used)
Preparation
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Monitoring vital signs (ideally use continuous oximetry)
Support oxygenation and ventilation as needed
Counsel the parents
Open the dressing pack using aseptic technique and drop the opened needle, syringe,
and 3-way tap onto the plastic drape
Fill the pot with antiseptic solution
Wash hands and put on sterile gloves
Procedure
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Attach the butterfly to 3 way and to syringe
Nurse to firmly hold the baby in the supine position
Clean the skin over the anterior hemithorax with antiseptic
Pierce the skin of the 2nd or 3rd intercostal space in the midclavicular line with the
butterfly at 90o to the skin; take care to avoid the nipple area. Gently aspirate the needle
as you go; you will probably feel a change in resistance as you enter the pleural space.
Decrease the angle of the needle slightly.
Once you are in the pneumothorax (pleural space) gas should freely enter the syringe as
you aspirate.
Continue to aspirate and expel the air using the 3 way until no further gas is aspirated
(the leak has stopped) or until you are ready to place an ICC. If gas just continues to fill
the syringe then the butterfly will definitely need to be replaced with an ICC.
Remove the needle either when gas has stopped aspirating or when a ICC is placed.
Do a CXR after the procedure to confirm the air leak has resolved.
Figure 16. Draining pneumothorax with a butterfly needle
http://t3.gstatic.com/images?q=tbn:ANd9GcQVCG_GRhgR4M-FDF_6rKWBKBjQvxXpGi1SfN_
SIKgqOOPX2H-5
Inserting an Intercostal catheter (ICC)
Equipment
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Sterile drapes
Dressing pack
Cotton swabs
Antiseptic solution (e.g. 70% alcohol)
Sterile gloves
Sterile gown
ICC (size 8F) 25
Small curved artery forceps (‘mosquito type’)
artery forceps longer straight
Scalpel blade
Lignocaine 1%
Drawing up needle (21G)
25G needle
2cc syringe
Heimlich valve or underwater drain system
sterile water
drain tubing with tunnel connector including adaptors
functioning suction
silk or nylon suture 2.0, 3.0 or 4.0 with needle
needle holder
dressings (clear plastic)
tape
25
IF an ICC is unavailable it is possible (though not ideal) to use a 12 or 14G intravenous catheter and
to tape it securely in situ. Attach to a 3 way tap and syringe. Insert as per butterfly needle technique. Leave in
situ and aspirate regularly. Beware the catheter falling out or kinking because it is much softer than an ICC.
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CPAP and the Baby with Difficult Breathing
117
Preparation
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Monitoring vital signs (ideally use continuous oximetry).
Support oxygenation and ventilation as needed.
Use local anaesthetic cream / patch on the skin if available.
Administer rectal paracetamol.
Counsel the parents.
Open and set up the underwater drain (if using this) and tubing, leaving the cap on the
end of the tubing.
Fill the drain with water and marked.
Open the dressing pack and open the ICC, instruments including scalpel, needles and
syringes (and Heimlich valve if using this) onto the tray.
Fill the pot with antiseptic solution.
Wash hands
Gown up and put on sterile gloves.
Attach the 25G needle / 2cc syringe and draw up 0.5cc of lignocaine.
Remove the stylet from the ICC.
Clamp the ICC with the straight artery forceps several cms down the ICC
Nurse to firmly secure the baby in the supine position rolled with the affected side
elevated 60o using a towel, arm held above head.
Wash the area over the anterior and lateral chest with antiseptic.
Drape
Locate the landmarks (the nipple, the anterior axillary line, the 4th or 5th intercostal space)
and estimate the length of ICC needed inside the chest (distance from incision site to
midclavicle)
Infiltrate the skin and subcutaneous tissues through to pleura with the lignocaine.
Make a small incision (2-5mm) through the skin and the immediate sub-cutaneous
tissues with the scalpel
Place the small mosquito forceps over the cut and ‘gently’ push and ‘split’ (blunt
dissection) the tissue by slowly opening / closing the forceps. Stay as close to the
‘upper edge of the rib below’ the cut as you can (this is difficult to discern in a small
baby). Do this until you feel a give in resistance as you enter the pleural space.
Remove the forceps and then, holding the tip of the ICC with the curved artery forceps,
pass the clamped ICC up through the opening you have just created, directing it
towards the head and mid-clavicle.
You should see some humidity or vapour in the ICC as it enters the pleural space.
Advance it so all holes in the side of the tube are inside the chest.
Attach either the Heimlich valve or the tubing / underwater drain system. You should see
‘flapping’ of the Heimlich valve or swinging of the water if the drain is correctly placed in
the pleural space. If there is no swinging gently advance the drain until swinging is seen
Secure the drain with a suture around the entry site and tied to the ICC.
Secure again with tapes in a ‘bridge’ – plasters to each side of the chest next to the
tube, then a third piece between each of these and across the
Cover with clear dressings (e.g. tegaderm) in a ‘sandwich’ to seal the tube entry site.
Anchor the tubing to the patient’s chest so it can’t pull out.
CPAP and the Baby with Difficult Breathing
–
–
If using a Heimlich valve, ensure the valve balloon is ‘flapping’; if it isn’t then the position
of the drain may need to be adjusted.
If using an underwater drain, connect to gentle suction (10-15cm) and ensure the water
is bubbling and swinging in the tube. Continue suction until the bubbling ceases for
~ 24hrs and the pneumothorax is resolved on CXR. Stop the suction and repeat CXR
again in 24hrs; remove the tube if no reaccumulation of air. Use a single stitch to close
the wound and cover with a tegaderm or equivalent dressing.
Post procedure
–
–
CXR to confirm position (both AP and lateral) and exclude kinking. The catheter should
not cross the midline (pull it back if it does).
Ongoing analgesia until ICC removed
Figure 17. Heimlich valve
http://www.arrowintl-europe.com/webcat/user/bilder/1058946749__AI-01500-E-2.jpg
Figure 18. Correct placement and taping of an intercostal catheter
http://archive.student.bmj.com/issues/05/07/education/images/view_7.jpg
119
12.9
Bedside monitoring chart for babies on CPAP
13.
PRETEST / POST-TEST
1. List 3 neonatal conditions that can be treated with CPAP.
2. List 2 conditions where CPAP is unlikely to be useful.
3. How does CPAP help a baby to breathe?
4. What is the correct SpO2 range for a baby on CPAP? Give answers for both preterm
and term babies.
5. Write 3 things on the CPAP machine that you must check regularly while it is in use on
the baby.
6. Write 3 things on the baby that you must check while he / she is on CPAP.
7. Can you feed a baby while he / she is on CPAP? If yes, describe how.
8. List 3 things that must be set on the CPAP machine
9. What is the usual starting pressure setting for CPAP for a 1.5kg baby who has RDS?
How many cms water?
10. Look at the picture of the blender graph.
120
CPAP and the Baby with Difficult Breathing
121
–
–
–
Using a flow of 3L Oxygen and 3L Air gives an FiO2 of...%
Using a flow of 5L Oxygen and 2L Air gives an FiO2 of...%
The doctor has asked for 60% oxygen. List 3 different flow combinations that will
give approximately FiO2 60%:
11. Apart from monitoring vital signs and the machine, list 3 elements of nursing care which
are very important on CPAP.
14.
CASE SCENARIOS FOR CPAP TRAINING
Baby who is deteriorating
Baby with a possible blocked tube
The baby who is improving
There is no bubbling in the expiratory bottle
Scenario 1
Baby 1 is 1.7 kg and was born at 31 weeks gestation. He was started on CPAP at 12 hours
of age because Dr. John thought he had RDS of prematurity (hyaline membrane disease).
He had not had any apnoea but had difficult breathing even when he was on face mask
oxygen at 6L/minute.
He was started on 5cm CPAP and 30% FiO2. The nurse looking after him had to increase
the FiO2 to 40% in the first hour after CPAP started to get the baby’s SpO2 to 95%. He
was stable for the rest of the day. He began minimum volume feeds of EBM by OGT at 24
hours of age.
On day 3 it is noted that he has been deteriorating for several hours. His work of breathing
has increased a lot, his respiratory rate and pulse rates have increased significantly, his
oxygen requirement has increased from 40% to 65% over the preceding 6 hours. His
perfusion is not very good and he has had several apnoeas, all responding to stimulation.
He is less active.
1. List possible reasons for his deterioration.
2. List a series of actions that are needed to help work out the actual reason for
his deterioration.
Scenario 2
Nurse Maria is caring for a 1.5kg baby, 32 weeks gestation who is on CPAP. The baby is
2 days old and was started on CPAP on day 1 of life for RDS. He is doing well on CPAP
on a pressure of 5cms, FiO2 45%. The settings have been stable since he was started on
CPAP; his SpO2 has been kept between 88 and 93% on these settings. Suddenly, half
an hour after his observations had been stable, the baby desturates to 75%. He appears
agitated and has increased recessions, respiratory rate and pulse rate. Maria quickly checks
the circuit and machine and all connections are intact and the settings (flows, pressure) are
as ordered. There is still bubbling in the expiratory bottle. Auscultation of the chest is equal
122
CPAP and the Baby with Difficult Breathing
123
on both sides.
15.
SAMPLE TIMETABLE FOR A 1 DAY CPAP TRAINING
1. What could be the problem?
0830-0845
Introduction / Welcome
2. What should Nurse Maria do?
0845-0930
Pretest (10 questions)
0930-1015
CLINICAL theory presentation
·
What is CPAP?
·
What are the indications for using CPAP?
·
How is CPAP implemented?
1015-1030
Morning tea
1030-1100
BIOMEDICAL theory presentation
·
How does the CPAP machine work?
1100-1200
NURSING theory presentation
·
Nursing care of the baby on CPAP
·
Nursing care of the CPAP machine
1200-1300
Lunch
1300 - 1430
Demonstration and group practice (3 scenarios, 30mins each)
i) setting up the CPAP machine to use
ii) using the CPAP machine (changing settings, alarms, monitoring)
iii) preparing and inserting a nasopharyngeal (NP) tube
1430-1445
Afternoon tea
1445-1545
2. What could be the reasons?
Demonstration and group practice (3 scenarios 20mins each)
v) changing a NP tube (recognising signs and correct actions)
vi) cleaning the CPAP machine after use
vii) using the CPAP monitoring form
1545-1630
Case scenarios (3) – small groups
3. What should she do to try and fix the problem?
1630-1700
Post-test (10 questions)
Scenario 3
Nurse Jo is caring for baby Carlos, a 1.3kg baby of 30 weeks gestation. He has been
on CPAP for 5 days, since he was 8 hours of age when he developed significant RDS,
probably due to HMD. At his sickest he needed CPAP 7cms and 70% oxygen. He is now on
25% oxygen and pressure of 5cm. He is stable, tolerating his milk feeds by OGT and does
not have any apnoea episodes. He is on aminophylline IV.
1. What is the appropriate management regarding the CPAP at this stage?
2. What steps do you need to do?
Scenario 4
Nurse Anna is doing her routine observations of a baby 1.9kg on CPAP who had RDS
from probable neonatal pneumonia. She does her checks on the baby and doesnt find any
problem however when she checks the CPAP machine she notices there is no bubbling in
the expiratory bottle.
1. Is this a problem? If yes, why is it a problem?
124
CPAP and the Baby with Difficult Breathing
Q/A and close
125
16.
SUPERVISION SHEET
No babies in nursery who need CPAP who
are not receiving CPAP at the time of visit
This sheet is prepared as a GUIDE to what could be reviewed during a supervision exercise
to a hospital where CPAP is used and as a follow up after training. A suggested scoring
system is listed below. Use the protocols, policies and checklists in the manual as your
standard against which to assign scores. If there are no babies on CPAP during the visit you
can use medical records and mannequins and hypothetical scenarios to determine the skills
/ competencies of the staff.
The purpose of the exercise is to have an idea of how competently the CPAP is being
implemented, to discover areas that need strengthening in care and to help target areas
which may need better focus in training. It is always a good idea to compare serial
supervision assessments against one another in order to detect improvement / deterioration
in care over time.
HOSPITAL
SCORE
COMMENTS
Has 24 hour CXR
Babies in nursery on CPAP are having regular
monitoring observations done and recorded
MEDICAL STAFF
Know indications for starting CPAP
Knows correct start settings for CPAP
Knows correct oxygen ranges for babies
treated with CPAP
Knows differential diagnosis for why a baby
may be getting worse on CPAP
Know indications for stopping CPAP
Know signs a baby is deteriorating
Knows what to check on the machine and on
the baby when a baby is deteriorating
Has reliable oxygen supply
Knows correct actions for the problems with
the CPAP machine (see table p. 73)
Has safe ratio of nurses to babies in neonatal
area
Can correctly explain how the CPAP works
and the individual components of the machine.
Has 24 hour medical cover with staff trained
in CPAP
NURSING STAFF
NURSERY
Number of babies who have been treated with CPAP / month and number of months CPAP has
been in use.
- ......... / month
- ........ months
Essential equipment and supplies for CPAP
available and in good working order
Babies in nursery on CPAP at time of visit
have suction equipment and equipment for
tube change ready at bedside
Written protocols for CPAP exist and readily
available
Job aides for CPAP exist and readily available
Know signs a baby is deteriorating
Knows what to check on the machine and on
the baby when a baby is deteriorating
Can correctly demonstrate how to set up the
CPAP machine
Demonstrates correct suction technique
Demonstrates correct technique for inserting
and / or changing CPAP nasal tube
Knows the list of items that require regular
monitoring for a baby on CPAP and for the
machine
Scoring
Babies in nursery on CPAP at time of review
have correct indication for CPAP
CPAP being used correctly – machine set up
correct, oxygen use correct – for babies in
nursery on CPAP at time of visit
126
CPAP and the Baby with Difficult Breathing
Clinical standards
Supplies / equipment
3
good care / meets standards
all present and in working
order
2
some need for improvement to reach standard care
some missing or broken
127
1
marked need for improvement to reach standard care
many items missing or broken
0
care not provided or harmful practices
Majority / all not present or
broken
17.
REFERENCES
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Syndrome and Home Montioring. Committee on Fetus and Newborn. Paediatrics 2003;
111; 914-917. Accessed online 28.3.2011 at http://pediatrics.aappublications.org/cgi/
reprint/111/4/914.pdf
2. Royal Prince Alfred Hospital Newborn Care Clinical Guideline Apneoa and Bradycardia.
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3. Heimler R, Langlois J, Hodel DJ, Nelin LD, Sasidharan P. Effect of positioning on the
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4. Schmidt B, Roberts RS, Davis P, Doyle LW, Barrington KJ, Ohlsson A, et al. Caffeine
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Caffeine for Apnea of Prematurity Trial Group Caffeine for Apnea of Prematurity trial:
benefits may vary in subgroups. J Pediatr. 2010 Mar;156(3):382-7
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8. Target ranges of oxygen saturation in extremely preterm infants. SUPPORT Study
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PJ, Morris BH, Laroia N, Phelps DL, Poindexter BB, Cotten CM, Van Meurs KP, Duara
S, Narendran V, Sood BG, O’Shea TM, Bell EF, Ehrenkranz RA, Watterberg KL, Higgins
RD. N Engl J Med 2010;362(21):1959-69.
9. The Clinical Use of Oxygen in Hospitals with limited resources. Guidelines for
health workers, hospital engineers and programme managers. Draft version WHO
2009. Available at http://www.theunion.org/images/stories/download/OXresources/
Technicalresources/The%20Clinical%20Use%20of%20Oxygen%20in%20Hospitals%20
with%20Limited%20Resources.pdf
10. Royal Prince Alfred Hospital Newborn Care Guidelines. Oxygen therapy. Accessed on
line at http://www.sswahs.nsw.gov.au/rpa/neonatal/
11. Vain NE, Szyld EG, Prudent LM, Wiswell TE, Aguilar AM, Vivas NI. Oropharyngeal
and nasopharyngeal suctioning of meconium-stained neonates before delivery of their
shoulders: multicentre, randomised controlled trial. Lancet. 2004; 364(9434): 597-602
12. Avery ME, Tooley WH, Heller JB. Is chronic lung disease in low birth weight infants
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preventable? A survey of eight centers. Pediatrics. 1987; 79: 26 –30.
13. Morely CJ, COIN Trial collaborators. Nasal CPAP or ventilation for very pretem infants at
birth. A randomised trial – The COIN Trial. Ped Res. E-PAS2007:61; 6090.1 .
14. Lindner W, Vossbeck S, Hummler H and Pohlandt F. Delivery room management of
extremely low birthweight infants: spontaneous breathing or intubation? Pediatrics 103
(1999), 961-967.
15. Ho JJ, Subramaniam P, Henderson-Smart DJ, Davis PG. Continuous distending
pressure for respiratory distress in preterm infants. Cochrane Database of Systematic
Reviews 2002, Issue 2, Art. No.; CD002271. DOI: 10.1002/14651858, CD002271.
16. Ho JJ, Henderson-Smart DJ, Davis PG. Early versus delayed initiation of continuous
distending pressure for respiratory distress syndrome in preterm infants. Cochrane
Database of Systematic Reviews 2002; (2): CD002975.
17. Davis PG, Henderson-Smart DJ. Nasal continuous positive airways pressure
immediately after extubation for preventing morbidity in preterm infants. Cochrane
Database of Systematic Reviews 2003; Issue 2, Art. No.; CD000143. DOI:
10.1002/14651858, CD000143.
25. Rehan VK, Laiprasert J, Nakashima JM, Wallach M, McCool FD. Effects of continuous
positive airway pressure on diaphragm dimensions in preterm infants. J Perinatol.
2001;21 :521 – 4.
26. De Paoli AG, Davis PG, Faber B, Morely CJ. Devices and pressure sources for
adminsitration of nasal continuous positive airways pressure (NCPAP) in preterm
neonates. Cochrane Database of Systematic Reviews: Reviews 2008; (1).CD002977
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continuous positive airways pressure for preventing morbidity and mortality in very
preterm infants. Cochrane Database of Systematic Reviews: 2005 (3).CD001243.
28. Sweet, D., Bevilacqua, G., Carnielli, V., Greisen, G., Plavka, R., Didrik, S., et al. (2007).
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29. Tittley JG, Fremes SE, Wiesel RD, Christakis GT, Evans PJ, Madonik MM et al.
Haemodynamic and myocardial metabolic consequences of PEEP. Chest. 1985 Oct;
88(4):496-502.
18. Belenky DA, Orr RJ, Woodrum DE, Hodson WA. Is continuous transpulmonary
pressure better than conventional respiratory management of hyaline membrane
disaese? A controlled study. Pediatrics 58 (1976), 800-808.
19. Durbin GM, Hunter NJ, McIntosh N, Reynolds EO, Wimberley PD. Controlled trial of
continuous inflating pressure for hyaline membrane disease. Arch Dis Child 51 (1976),
163-169.
20. Buckmaster AG, Arnolda GR, Wright IM, Henderson-Smart DJ. CPAP use in babies
with respiratory distress in Australian special care nurseries. J Paediatr Child Health.
2007;43 :376 –382
21. Polin RA, Sahni R. Continuous Positive Airways Pressure: Old questions and new
controversies. J Neonatal-Perinatal Medicine 1 (2008) 1-10.
22. Henderson-Smart DJ, Subramaniam P, Davis PG. Continuous positive airway pressure
versus theophylline for apnea in preterm infants. Cochrane Database of Systematic
Reviews: Reviews 2001; (4).CD001072
23. All India Institute of Medical Sciences, Division of Neonatology, Clinical Protocols.
Protocol for Administering Continuous Positive Airway Pressure in Neonates (DRAFT).
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24. Wyszogrodski I, Kyei-Aboagye K, Taeusch HW Jr, Avery ME. Surfactant inactivation by
hyperventilation: conservation by end-expiratory pressure. J Appl Physiol. 1975;38 :461
–466
130
CPAP and the Baby with Difficult Breathing
131
18.
ANNEX 1: OXYGEN CONCENTRATION RATES
Varying oxygen concentrations (FiO2) that can be delivered via nasal flow oxygen (up to 1L/
minute) according to the baby’s weight and respiratory rate.
These are only accurate when low flow meters are used. These tables were provided by
personal communication Dr. Gaston Arnolda.
Flow rate of 100 mL/min
100
Weight (kg)
Flow rate of 50 mL/min
Weight (kg)
1.5
1.75
2
2.5
3
3.5
20
0.78
0.69
0.62
0.57
0.50
0.45
0.42
1.25
1.5
1.75
2
2.5
3
3.5
30
0.59
0.53
0.48
0.45
0.40
0.37
0.35
20
0.50
0.45
0.42
0.39
0.35
0.33
0.31
40
0.50
0.45
0.42
0.39
0.35
0.33
0.31
30
0.40
0.37
0.35
0.33
0.31
0.29
0.28
50
0.44
0.40
0.37
0.35
0.32
0.31
0.29
40
0.35
0.33
0.31
0.30
0.28
0.27
0.26
60
0.40
0.37
0.35
0.33
0.31
0.29
0.28
50
0.32
0.31
0.29
0.28
0.27
0.26
0.25
70
0.37
0.35
0.33
0.31
0.29
0.28
0.27
60
0.31
0.29
0.28
0.27
0.26
0.25
0.24
80
0.35
0.33
0.31
0.30
0.28
0.27
0.26
70
0.29
0.28
0.27
0.26
0.25
0.24
0.24
90
0.34
0.32
0.30
0.29
0.27
0.26
0.26
80
0.28
0.27
0.26
0.25
0.25
0.24
0.24
100
0.32
0.31
0.29
0.28
0.27
0.26
0.25
90
0.27
0.26
0.26
0.25
0.24
0.24
0.23
100
0.27
0.26
0.25
0.25
0.24
0.23
0.23
FiO2
Respiratory rate
Respiratory rate
50
1.25
Flow rate of 150 mL/min
150
Flow rate of 75 mL/min
132
Weight (kg)
Weight (kg)
1.25
1.5
1.75
2
2.5
3
3.5
20
1.00
0.93
0.83
0.75
0.64
0.57
0.52
1.25
1.5
1.75
2
2.5
3
3.5
30
0.78
0.69
0.62
0.57
0.50
0.45
0.42
20
0.64
0.57
0.52
0.48
0.43
0.39
0.36
40
0.64
0.57
0.52
0.48
0.43
0.39
0.36
30
0.50
0.45
0.42
0.39
0.35
0.33
0.31
50
0.55
0.50
0.46
0.43
0.38
0.35
0.33
40
0.43
0.39
0.36
0.34
0.32
0.30
0.29
60
0.50
0.45
0.42
0.39
0.35
0.33
0.31
50
0.38
0.35
0.33
0.32
0.30
0.28
0.27
70
0.46
0.42
0.39
0.36
0.33
0.31
0.30
60
0.35
0.33
0.31
0.30
0.28
0.27
0.26
80
0.43
0.39
0.36
0.34
0.32
0.30
0.29
70
0.33
0.31
0.30
0.29
0.27
0.26
0.25
90
0.40
0.37
0.35
0.33
0.31
0.29
0.28
80
0.32
0.30
0.29
0.28
0.26
0.25
0.25
100
0.38
0.35
0.33
0.32
0.30
0.28
0.27
90
0.31
0.29
0.28
0.27
0.26
0.25
0.24
100
0.30
0.28
0.27
0.26
0.25
0.25
0.24
CPAP and the Baby with Difficult Breathing
FiO2
Respiratory rate
Respiratory rate
75
FiO2
FiO2
133
Respiratory rate
20
1.00
1.00
1.00
1.00
0.93
0.81
0.72
30
1.00
1.00
0.89
0.81
0.69
0.61
0.55
40
0.93
0.81
0.72
0.66
0.57
0.51
0.47
50
0.78
0.69
0.62
0.57
0.50
0.45
0.42
60
0.69
0.61
0.55
0.51
0.45
0.41
0.38
70
0.62
0.55
0.50
0.47
0.42
0.38
0.36
80
0.57
0.51
0.47
0.43
0.39
0.36
0.34
90
0.53
0.48
0.44
0.41
0.37
0.34
0.32
100
0.50
0.45
0.42
0.39
0.35
0.33
0.31
FiO2
Flow rate of 300 mL/min
300
Weight (kg)
1.25
1.5
1.75
2
2.5
3
3.5
20
1.00
1.00
1.00
0.93
0.78
0.69
0.62
30
0.98
0.85
0.76
0.69
0.59
0.53
0.48
40
0.78
0.69
0.62
0.57
0.50
0.45
0.42
50
0.67
0.59
0.54
0.50
0.44
0.40
0.37
60
0.59
0.53
0.48
0.45
0.40
0.37
0.35
70
0.54
0.48
0.44
0.42
0.37
0.35
0.33
80
0.50
0.45
0.42
0.39
0.35
0.33
0.31
90
0.47
0.42
0.39
0.37
0.34
0.32
0.30
100
0.44
0.40
0.37
0.35
0.32
0.31
0.29
FiO2
Flow rate of 250 mL/min
250
Weight (kg)
1.25
1.5
1.75
2
2.5
3
1.25
1.5
1.75
2
2.5
3
3.5
20
1.00
1.00
1.00
1.00
1.00
0.93
0.83
30
1.00
1.00
1.00
0.93
0.78
0.69
0.62
40
1.00
0.93
0.83
0.75
0.64
0.57
0.52
50
0.90
0.78
0.70
0.64
0.55
0.50
0.46
60
0.78
0.69
0.62
0.57
0.50
0.45
0.42
70
0.70
0.62
0.56
0.52
0.46
0.42
0.39
80
0.64
0.57
0.52
0.48
0.43
0.39
0.36
90
0.59
0.53
0.48
0.45
0.40
0.37
0.35
100
0.55
0.50
0.46
0.43
0.38
0.35
0.33
FiO2
Flow rate of 400 mL/min
400
Respiratory rate
Respiratory rate
200
Respiratory rate
Flow rate of 200 mL/min
Weight (kg)
Weight (kg)
1.25
1.5
1.75
2
2.5
3
3.5
20
1.00
1.00
1.00
1.00
1.00
1.00
1.00
30
1.00
1.00
1.00
1.00
0.98
0.85
0.76
40
1.00
1.00
1.00
0.93
0.78
0.69
0.62
50
1.00
0.98
0.87
0.78
0.67
0.59
0.54
60
0.98
0.85
0.76
0.69
0.59
0.53
0.48
70
0.87
0.76
0.68
0.62
0.54
0.48
0.44
80
0.78
0.69
0.62
0.57
0.50
0.45
0.42
90
0.72
0.64
0.57
0.53
0.47
0.42
0.39
100
0.67
0.59
0.54
0.50
0.44
0.40
0.37
FiO2
3.5
Flow rate of 600 mL/min
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CPAP and the Baby with Difficult Breathing
135
Weight (kg)
20
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.25
1.5
1.75
2
2.5
3
3.5
30
1.00
1.00
1.00
1.00
1.00
1.00
1.00
20
1.00
1.00
1.00
1.00
1.00
1.00
1.00
40
1.00
1.00
1.00
1.00
1.00
1.00
1.00
30
1.00
1.00
1.00
1.00
1.00
1.00
1.00
50
1.00
1.00
1.00
1.00
1.00
1.00
1.00
40
1.00
1.00
1.00
1.00
1.00
0.93
0.83
60
1.00
1.00
1.00
1.00
1.00
1.00
0.89
50
1.00
1.00
1.00
1.00
0.90
0.78
0.70
70
1.00
1.00
1.00
1.00
1.00
0.89
0.80
60
1.00
1.00
1.00
0.93
0.78
0.69
0.62
80
1.00
1.00
1.00
1.00
0.93
0.81
0.72
70
1.00
1.00
0.91
0.83
0.70
0.62
0.56
90
1.00
1.00
1.00
1.00
0.85
0.74
0.67
80
1.00
0.93
0.83
0.75
0.64
0.57
0.52
100
1.00
1.00
1.00
0.93
0.78
0.69
0.62
90
0.98
0.85
0.76
0.69
0.59
0.53
0.48
100
0.90
0.78
0.70
0.64
0.55
0.50
0.46
FiO2
Respiratory rate
Respiratory rate
600
FiO2
1. Hyaline membrane disease is also often referred to as ‘Respiratory distres syndrome’ however, so as to
prevent confusion with other causes of respiratory distress, in this manual we use only the term HMD to refer to
lung disease of prematurity presenting with respiratory distress.
2. Developed world settings recommend nurse:patient ratios of 1:1 – this has been modified to acknowledge
the human resource realities of developing nations.
Flow rate of 800 mL/min
Respiratory rate
800
Weight (kg)
1.25
1.5
1.75
2
2.5
3
3.5
20
1.00
1.00
1.00
1.00
1.00
1.00
1.00
30
1.00
1.00
1.00
1.00
1.00
1.00
1.00
40
1.00
1.00
1.00
1.00
1.00
1.00
1.00
50
1.00
1.00
1.00
1.00
1.00
0.98
0.87
60
1.00
1.00
1.00
1.00
0.98
0.85
0.76
70
1.00
1.00
1.00
1.00
0.87
0.76
0.68
80
1.00
1.00
1.00
0.93
0.78
0.69
0.62
90
1.00
1.00
0.94
0.85
0.72
0.64
0.57
100
1.00
0.98
0.87
0.78
0.67
0.59
0.54
2.5
3
3.5
FiO2
Flow rate of 1000 mL/min
1000
Weight (kg)
1.25
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1.5
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CPAP and the Baby with Difficult Breathing
2
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19.
ANNEX 2: PRETEST / POST-TEST (WITH ANSWERS)
1. List 3 neonatal conditions that can be treated with CPAP.
– apnoea
– RDS (HMD, pneumonia, aspiration, wet lung / TTN)
– pulmonary oedema
– post-extubation
2. List 2 conditions where CPAP is unlikely to be useful.
– very severe RDS
– severe apnoea
– severe cardiac instability / sepsis
3. How does CPAP help a baby to breathe?
– keeps lungs / alveoli from collapsing
– increases lung volume / functional residual capacity
– stimulates breathing
7. Can you feed a baby while he / she is on CPAP? If yes, describe how
– yes
– by OGT
– 2-3 hourly feeds of EBM if possible
– leave end of OGT open except for ½ hour after feed
8. List 3 things that must be set on the CPAP machine
– pressure
– flow of oxygen and air
– humidity
– set temperature of inhaled gas
9. What is the usual starting pressure setting for CPAP for a 1.5kg baby who has RDS?
How many cms water?
– 5cms
10. Look at the picture of the blender graph.
4. What is the correct SpO2 range for a baby on CPAP? Give answers for both preterm
and term babies.
– Preterm: 88-93%
– Term: 90-95% (95-98% if asphyxia, meconium aspiration, sepsis or pulmonary
hypertension)
5. Write 3 things on the CPAP machine that you must check regularly while it is in use on
the baby.
– oxygen supply
– circuit connections
– machine settings
– set temperature vs temperature reading on control box
– ‘rain’ in tubing / humidity
– bubbling
– water level in bottles
6. Write 3 things on the baby that you must check while he / she is on CPAP.
– vital signs
– respiratory effort
– peripheral circulation
– general condition / settledness
– gastric distension
– secretions
– nasal skin
– tube security and placement
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CPAP and the Baby with Difficult Breathing
–
–
–
–
Using a flow of 3L Oxygen and 3L Air gives an FiO2 of ..61... %
Using a flow of 5L Oxygen and 2L Air gives an FiO2 of ..77.. %
The doctor has asked for 60% oxygen. List 3 different flow combinations that will
give approximately FiO2 60%.
3/3 (61%), 4/4 (61%), 4/3 (66%)
11. Apart from monitoring vital signs and the machine, list 3 elements of nursing care whch
are very important on CPAP.
139
–
–
–
–
–
–
–
care of the nose
tube care including suction if you think it is blocked
positioning / swaddling and ensuring comfort
feeding
infection prevention
ensuring SpO2 is in required range
calling a doctor if suspected deterioration
20.
ANNEX 3: CASE SCENARIOS FOR CPAP TRAINING (WITH
ANSWERS)
Baby who is deteriorating
Baby with a possible blocked tube
The baby who is improving
There is no bubbling in the expiratory bottle
Scenario 1
Baby 1 is 1.7 kg and was born at 31 weeks gestation. He was started on CPAP at 12 hours
of age because Dr. John thought he had RDS of prematurity (hyaline membrane disease).
He had not had any apnoea but had difficult breathing even when he was on face mask
oxygen at 6L/minute.
He was started on 5cm CPAP and 30% FiO2. The nurse looking after him had to increase
the FiO2 to 40% in the first hour after CPAP started to get the baby’s SpO2 to 95%. He
was stable for the rest of the day. He began minimum volume feeds of EBM by OGT at 24
hours of age.
On day 3 it is noted that he has been deteriorating for several hours. His work of breathing
has increased a lot, his respiratory rate and pulse rates have increased significantly, his
oxygen requirement has increased from 40% to 65% over the preceding 6 hours. His
perfusion is not very good and he has had several apnoeas, all responding to stimulation.
He is less active.
1. List possible reasons for his deterioration.
If a baby deteriorates after having been stable or improving on CPAP it may be due to a
machine / circuit problem or it may be a patient problem.
a. A Machine / circuit problem
i) circuit disconnection
ii) nasal tube blockage
iii) oxygen supply run out or turned off
b. A Baby problem
i) Recurrent Apnoea
ii) Underlying lung disease is worsening
iii) Complication of CPAP
a) lung overdistension, pneumothorax
b) gastric distension, aspiration
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CPAP and the Baby with Difficult Breathing
141
iv) Development of a new problem such as
a) sepsis / pneumonia
b) PDA
2. List a series of actions that are needed to help work out the actual reason for his
deterioration.
a. Call for help (consider whether to)
b. Increase the FiO2 – by 10-20% or more if needed
i) Check for apnoea
ii) If present, stimulate the baby
iii) If the baby does not begin breathing within 20-30 seconds, take off CPAP
and ambubag / mask with oxygen
c. Quick Machine Check
i) Connections intact?
ii) Oxygen on and cylinder full?
iii) Settings correct (PEEP, oxygen, flow rate)?
iv) Bubbling?
a) Fix any problem immediately
b) If no improvement, continue
d. Quick clinical assessment
i) Auscultation - ?pneumothorax
a) If unsure, transilluminate or order portable CXR
ii) Hypotension / reduced cardiac output?
a) Try bolus of fluid (10cc/kg normal saline)
e. Check the tube - ?obstruction
i) Suction the tube and airway
ii) Change the tube if you have any concern that it is blocked
iii) If this does not resolve the problem, continue
f. Increase the settings
i) Oxygen 5% increments
ii) Pressure increments 1cm, up to a maximum of 8; do not increase if suspect
hyperinflation
g. Urgent CXR if possible
1. What could be the problem?
The likely problem is either a blocked tube or an acute deterioration in lung disease such as
a pneumothorax or aspiration.
2. What should Nurse Maria do?
First she should increase the oxygen by 10%. Then she should exclude a blocked tube. To
do this she should suction the tube – if the catheter does not easily pass to the full length of
the tube then she should quickly remove and replace the tube with a new one. If the suction
catheter does easily pass through the tube but the baby remains desaturated then the baby
may have a pneumothorax or an acute aspiration. The oxygen may be increased further to
try and improve saturations. The doctor should be urgently called. The baby will need to be
transilluminated to check for pneumothorax, the pressure may need to be increased and a
CXR should be urgently ordered, if possible.
Scenario 3
Nurse Jo is caring for baby Carlos, a 1.3kg baby of 30 weeks gestation. He has been
on CPAP for 5 days, since he was 8 hours of age when he developed significant RDS,
probably due to HMD. At his sickest he needed CPAP 7cms and 70% oxygen. He is now on
25% oxygen and pressure of 5cm. He is stable, tolerating his milk feeds by OGT and does
not have any apnoea episodes. He is on aminophylline iv.
1. What is the appropriate management regarding the CPAP at this stage?
The baby is ready for a trial off CPAP.
2. What steps do you need to do?
Hold the feeds. Explain that you will try the baby off CPAP to the parents, and what this will
involve. Ensure you have prepared resuscitation equipment and a spare pre-cut tube and
tapes next to the bed in case the baby fails trial off. Prepare an oxygen mask or nasal prongs
or headbox to use immediately after taking off the CPAP. After 2 hours off feeds, suction the
tube, the other nostril and the mouth. You are ready to trial the baby off.
Scenario 2
Scenario 4
Nurse Maria is caring for a 1.5kg baby, 32 weeks gestation who is on CPAP. The baby is 2
days old and was started on CPAP on day 1 of life for RDS. He is doing well on CPAP on
a pressure of 5 cms, FiO2 45%. The settings have been stable since he was started on
CPAP; his SpO2 has been kept between 88 and 93% on these settings. Suddenly, half
an hour after his observations had been stable, the baby desturates to 75%. He appears
agitated and has increased recessions, respiratory rate and pulse rate. Maria quickly checks
the circuit and machine and all connections are intact and the settings (flows, pressure) are
as ordered. There is still bubbling in the expiratory bottle. Auscultation of the chest is equal
on both sides.
Nurse Anna is doing her routine observations of a baby 1.9kg on CPAP who had RDS
from probable neonatal pneumonia. She does her checks on the baby and doesnt find any
problem however when she checks the CPAP machine she notices there is no bubbling in
the expiratory bottle.
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CPAP and the Baby with Difficult Breathing
1. Is this a problem? If yes, why is it a problem?
Yes, this is a problem. It is a problem because no bubbling means that the CPAP is not
working.
143
2. What could be the reasons?
It could be a problem with the baby or a problem with the machine/circuit. Problems with
the baby could be a) a leak around the interface or out the mouth or b) apnoea. Problems
with the machine could be a) a disconnection or leak somewhere in the circuit, b) no gas
flow due to power failure, disconnection or running out of oxygen, c) a kink in the tubing.
3. What should she do to try and fix the problem?
Firstly she needs to try and determine whether it is a baby problem or a machine/circuit
problem. She should check if the baby is breathing or if there is apnoea. If there is
apnoea, the baby should be stimulated and the oxygen increased. If the baby does not
immediately begin to breathe, she should be disconnected from the CPAP and the nurse
should bag / mask the baby and call the doctor. If there was no apnoea, the baby should
be disconnected from the circuit and the nurse should occlude the end of the circuit with
her hand. If bubbling returns then there is a problem of leaking at the baby’s nose / mouth.
Reconnect the baby. Check the interface is correctly inserted. Gently extend the baby’s
neck. Try closing the mouth by hand or with a dummy or with a gauze chin strap. See if
bubbling returns. If not, try increasing the flow by 1-2L/minute. If this doesn’t work, call the
doctor. If bubbling did not return when the baby was disconnected and the circuit occluded
then there is a circuit / machine problem. Provide the baby with facemask oxygen. Check
the circuit and machine for kinks or disconnections. Check the gas flows are on, the air
compressor is on and the oxygen supply is on. If no problem can be found and the bubbling
does not continue, change machines.
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